Chapter 13: Drugs Used for Sleep

12. The nurse is assessing a patient who is being evaluated in an outpatient clinic for complaints of back pain. The patient reports taking diphenhydramine for insomnia related to job stress. Which statement by the nurse is accurate regarding this medication? a. "This medication should only be taken for 1 week." b. "This medication can cause nausea." c. "The medication should not be taken after eating a high-fat meal." d. "This is an herbal medication that has been used for hundreds of years."

ANS: A Antihistamines (particularly diphenhydramine and doxylamine) have sedative properties that may be used for short term treatment of mild insomnia. They are common ingredients in over-the-counter (OTC) sleep aids. Tolerance develops after only a few nights of use; increasing the dose actually causes a more restless and irregular sleep pattern. Diphenhydramine does not cause nausea. There is no restriction on taking diphenhydramine after a high-fat meal. Diphenhydramine is not an herbal medication.

4. The nurse is assessing a patient prior to discharge from same day surgery following an incisional breast biopsy. When assessing the patient's central nervous system (CNS) function following sedative-hypnotic therapy, what will the nurse include? (Select all that apply.) a. Level of alertness b. Orientation c. Ability to perform motor functions d. Blood pressure e. Usual pattern of sleep

ANS: A, B, C Because sedative hypnotics depress overall CNS function, the nurse should identify the patient's level of alertness and orientation and ability to perform motor functions. Blood pressure is a vital sign and falls under cardiovascular assessment. Usual sleep pattern should be obtained for information on sleep pattern disruption but not for CNS function.

3. What can occur as a result of rapid withdrawal from long-term use of barbiturate therapy? (Select all that apply.) a. Anxiety b. Delirium c. Weakness d. Grand mal seizures e. Severe pain

ANS: A, B, C, D Anxiety, delirium, weakness, and grand mal seizures can be symptoms of rapid withdrawal from long-term use of barbiturate therapy. Severe pain is not a symptom of rapid withdrawal from long-term use of barbiturate therapy.

1. Why are benzodiazepines often preferred over barbiturates? (Select all that apply.) a. They have selective action at specific receptor sites. b. There is a wide range of safety between therapeutic and lethal levels. c. REM sleep is decreased to a lesser extent. d. Accidental overdoses are well tolerated. e. There are no hypotensive episodes when rising to a sitting position.

ANS: A, B, C, D The selectivity of specific drugs at receptor sites accounts for the wide variety of uses. There is a wide safety margin between the therapeutic and lethal dosages for these drugs. Benzodiazepines decrease REM sleep to a lesser extent. Intentional and unintentional overdoses of benzodiazepines are often well tolerated and not fatal. There are transient hypotensive episodes with benzodiazepine therapy.

4. A patient receiving diazepam (Valium) is complaining of nausea and vomiting and is becoming jaundiced. Which type of blood work will be performed? a. Renal function tests b. Liver function tests c. Clotting times d. Electrolyte panels

ANS: B Liver function tests will be performed because nausea, vomiting, and jaundice can be indicative of hepatotoxicity. Abnormal liver function test results (i.e., elevated bilirubin, aspartate transaminase [AST], alanine transaminase [ALT], gamma-glutamyl transferase [GGT], and alkaline phosphatase levels, as well as prothrombin time) are indicative of hepatotoxicity. Benzodiazepines do not affect the kidneys, clotting times, and electrolytes.

8. A patient has been prescribed lorazepam (Ativan), a benzodiazepine used to treat insomnia. Which action will the nurse take? a. Advise the patient to take the medication with food. b. Assess the patient's blood pressure in sitting and lying positions. c. Inform the patient to discontinue the medication once sleep improves. d. Instruct the patient to lie down before taking the medication.

ANS: B Measuring blood pressure in sitting and lying positions is important to assess for transient hypotension. Ativan does not have to be taken with food. Rapid discontinuance of the medication after long-term use may result in symptoms similar to those of alcohol withdrawal. Gradual withdrawal of benzodiazepines is over 2 to 4 weeks. Medications should be taken sitting up.

7. Which sleep pattern stage diminishes as an effect of aging? a. Stage I b. Stage II c. Stage III d. Stage IV

ANS: D As we age, stage IV sleep diminishes. Many people older than 75 years do not demonstrate any stage IV sleep patterns. Between 2% and 5% of sleep is stage I. Stage II comprises about 50% of normal sleep time. Stage III is a transition between lighter sleep and deeper sleep.

6. Which two phases make up normal sleep? a. Hypnagogic and hypnopompic b. Rapid eye movement (REM) and non REM c. Alpha and beta d. Delta and theta

ANS: B Normal sleep can be divided into two phases, REM and non REM. Hypnagogic is the state between waking and sleeping; hypnopompic is the transition between sleeping and waking states. Beta waves are those associated with day to day wakefulness. During periods of relaxation while still awake, our brain waves become slower, increase in amplitude, and become more synchronous. These types of waves are called alpha waves. The first stage of sleep is characterized by theta waves. During a normal night's sleep, a sleeper passes from the theta waves of stages 1 and 2 to the delta waves of stages 3 and 4. Delta waves are the slowest and highest amplitude brain waves.

14. The nurse is administering Somnote to a patient. When providing medication education to the patient, the nurse will include that Somnote should be a. thoroughly chewed. b. taken with a full glass of water. c. taken on an empty stomach. d. taken only before bedtime.

ANS: B Somnote is available in capsule form and should not be chewed, should be taken with a full glass of water, should be taken after meals, and is usually ordered to be taken three times a day after meals.

11. The nurse is explaining the use of medications to a patient with insomnia. Which statement about sedatives is true? a. A sedative will produce sleep. b. Sedatives increase the total time in REM sleep. c. Increased relaxation occurs with sedatives. d. Sedatives are more potent than hypnotics.

ANS: C A hypnotic is a drug that produces sleep; a sedative quiets the patient and gives a feeling of relaxation and rest, not necessarily accompanied by sleep. Sedatives do not increase the total time in REM sleep. A small dose of a drug may act as a sedative, whereas a larger dose of the same drug may act as a hypnotic and produce sleep.

2. An older adult patient received a hypnotic agent at 9:00 PM. At 2:00 AM, the nurse discovers that the patient has removed her gown and is attempting to get out of bed without assistance. What type of medication effect is the patient exhibiting? a. Allergic b. Hypersensitivity c. Paradoxical d. Therapeutic

ANS: C A paradoxical effect may occur in older adult patients. This includes periods of excitement, confusion, restlessness, and euphoria. Allergies to medications tend to manifest in skin or respiratory symptoms. A patient who is hypersensitive to a hypnotic would be difficult to rouse. A therapeutic effect for a hypnotic would be sedation.

9. Which disease is associated with insufficient sleep? a. Cancer b. Glaucoma c. Myocardial infarction d. Renal failure

ANS: C Individuals who sleep less than 5 hours a night have a threefold increased risk of heart attacks. Cancer, glaucoma, and renal failure are not associated with lack of sleep.

5. In addition to facilitating sleep, what is another benefit of sedatives? a. Increased pain control postoperatively b. Reduced bronchial secretions c. Decreased patient anxiety d. Increased patient alertness

ANS: C Preoperatively, sedatives will help decrease patient anxiety and facilitate sleep. Sedatives are not long acting enough to affect postoperative pain control. Sedatives do not affect bronchial secretions. Sedatives diminish patient alertness.

10. The nurse is caring for an older patient recently admitted to an assisted living center who is experiencing insomnia associated with the recent relocation. At bedtime, which nursing action will assist the patient to sleep? a. Offering the patient hot tea b. Encouraging the patient to ambulate in the hallway c. Performing back massage d. Administering an analgesic

ANS: C Providing a back rub will promote relaxation and reduce anxiety associated with a new environment. This would also provide an opportunity for the nurse to encourage the patient to express feelings. The patient should avoid products containing caffeine, such as coffee, tea, soft drinks, and chocolate. A quiet unwinding activity before bedtime is helpful for sleep promotion. Administering an analgesic is not an appropriate action.

3. For what conditions are benzodiazepines prescribed? a. Chronic amnesia b. Chronic insomnia c. Preoperative sedation d. Psychotic episodes

ANS: C The sedative-hypnotic effect of benzodiazepines facilitates surgical sedation. Short-acting benzodiazepines are administered intramuscular for preoperative sedation. They are also given intravenously for conscious sedation before short diagnostic procedures or for the induction of general anesthesia. Benzodiazepines are not recommended for long-term use and do not affect amnesia. Benzodiazepines are a poor choice for the treatment of chronic insomnia because of their risk for habituation. Benzodiazepines do not have an anti psychotic effect.

1. The nurse finds that a patient is extremely agitated, yells frequently, and is attempting to get out of bed without assistance. What is the nurse's initial action? a. Administer zolpidem after taking the patient's vital signs. b. Close the patient's door for privacy after administering Tylenol. c. Administer benzodiazepine before calling the health care provider. d. Spend uninterrupted time listening to the patient.

ANS: D Assessing the patient's level of anxiety is important. The patient may only need someone to listen to what stressors he or she is facing. The nurse must assess the patient before medication can be administered.

13. When reviewing a patient's history and physical information, the nurse notes that the patient has physician's orders for chloral hydrate and warfarin. During assessment of this patient, the nurse observes areas of petechiae and ecchymosis on the upper and lower extremities. The most appropriate lab work for the nurse to assess next is a. liver function studies. b. C-reactive protein. c. sedimentation rate. d. prothrombin time.

ANS: D Chloral hydrate may enhance the anticoagulant effects of warfarin. The patient should be observed for petechiae, ecchymoses, nosebleeds, bleeding gums, dark tarry stools, and bright red or coffee-ground emesis. Prothrombin time should be monitored, and the physician should reduce the dosage of warfarin, if necessary.