Chapter 20 Anxiolytic and Hypnotic Agents
Benzodiazepines Contraindications/Cautions
-Allergy to benzo -psychosis -acute narrow angle glaucoma -shock -coma -acute alcohol intox -pregnancy
Benzodiazepines Adverse Effects
-Sedation -Drowsiness -depression -lethargy -blurred vision -confusion -dry mouth -constipation -nausea -vomiting -hypotension -urinary retention
Benzo drug interactions
-increase in CNS depression when taken with alcohol -increase in effect when taken with cimetidine (tagamet), oral contraceptives, or disulfiram (antabuse) med for alcoholics -decrease in effect if given with theophylline or ranitidine
29. The nurse is caring for a patient treated with flumazenil (Anexate) for benzodiazepine toxicity. After administering flumazenil what will the nurse carefully assess for? A) Agitation, confusion, and seizures B) Cerebral hemorrhage and dystonia C) Hypertension and renal insufficiency D) Hypotension, dysrhythmias, and cardiac arrest
Ans: A Feedback: Administration of flumazenil blocks the action of benzodiazepines. If the patient has been taking these medications for an extended period of time, the blockage of the drug's effects could precipitate an acute benzodiazepine withdrawal syndrome with symptoms including agitation, confusion, and seizures. Anexate does not cause cerebral hemorrhage and dystonia, hypertension, renal insufficiency, hypotension, dysrhythmias, and cardiac arrest.
30. The nurse administers promethazine (Phenergan) to the patient before sending the patient to the preoperative holding area. What is the rationale for administration of this drug? A) Sedation B) Oral secretions C) Hypotension and bradycardia D) Confusion
Ans: A Feedback: Antihistamines (promethazine, diphenhydramine [Benadryl]) can be very sedating in some people. They are used as preoperative medications and postoperatively to decrease the need for narcotics. Promethazine is not given for hypotension, bradycardia, confusion, or oral secretions.
17. A 75-year-old patient is brought to the emergency department by his family. The family relates that the patient is complaining of confusion, seizures, and abnormal perception of movement. The nurse reviews all of the medication bottles found in the house and suspects the patient overdosed on what medication? A) Benzodiazepine B) Antihypertensive C) Sedative D) Analgesic
Ans: A Feedback: Common manifestations of benzodiazepine toxicity include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Less common but more serious manifestations include confusion, abnormal perception of movement, depersonalization, psychosis, and seizures. These symptoms are not found in association with options B, C, or D.
16. The nurse assesses the patient who had an abrupt withdrawal of benzodiazepines for withdrawal syndrome and would recognize what symptoms as part of the syndrome? (Select all that apply.) A) Headache B) Nightmares C) Malaise D) Bradycardia E) Hypotension
Ans: A, B, C Feedback: Abrupt cessation of benzodiazepines may lead to a withdrawal syndrome characterized by nausea, headache, vertigo, malaise, and nightmares. Withdrawal symptoms may be caused by the abrupt separation of benzodiazepine molecules from their receptor sites and the resulting acute decrease in gamma-aminobutyric acid (GABA) neurotransmission. Because GABA is an inhibitory neurotransmitter, less GABA may produce a less inhibited central nervous system (CNS) and therefore symptoms of hyperarousal or CNS stimulation. The nurse would not categorize hypotension or bradycardia as indicating benzodiazepine withdrawal.
32. The nurse is teaching a class for nurses working in prenatal clinics about the danger associated with use of benzodiazepines during pregnancy and explains that what fetal anomalies result from maternal use of benzodiazepines during the first trimester of pregnancy? (Select all that apply.) A) Cleft lip or palate B) Inguinal hernia C) Cardiac defects D) Microencephaly E) Gastroschises
Ans: A, B, C, D Feedback: Benzodiazepines are contraindicated in pregnancy because a predictable syndrome of cleft lip or palate, inguinal hernia, cardiac defects, microcephaly, or pyloric stenosis occurs when they are taken in the first trimester. Gastroschises, when the abdominal organs are found outside the abdominal cavity, is not associated with use of benzodiazepine use in the first trimester.
31. What reasons can the nurse give for why barbiturates are no longer considered the mainstay for treatment of anxiety? (Select all that apply.) A) Adverse effects are more severe. B) There is an increased risk of physical tolerance. C) There is an increased risk of psychological dependence. D) The most common adverse effects are related to cardiac arrhythmias. E) Hypersensitivity reactions can sometimes be fatal.
Ans: A, B, C, E Feedback: The adverse effects caused by barbiturates are more severe than those associated with other, newer sedatives/hypnotics. For this reason, barbiturates are no longer considered the mainstay for the treatment of anxiety. In addition, the development of physical tolerance and psychological dependence is more likely with the barbiturates than with other anxiolytics. The most common adverse effects are related to central nervous system (CNS) depression. Hypersensitivity reactions to barbiturates are sometimes fatal.
27. The nurse is caring for a patient who has a sedative hypnotic ordered. The nurse would consider this drug contraindicated if the patient had what disorder? A) Neurological diseases B) Liver failure C) Endocrine disorders D) Heart disease
Ans: B Feedback: Benzodiazepines undergo extensive hepatic metabolism. In the presence of liver disease, the metabolism of most benzodiazepines is slowed, with resultant accumulation and increased risk of adverse effects. Neurological disorders, endocrine disorders, and heart disease are not contraindications for the use of benzodiazepines
12. When compared with benzodiazepines, buspirone (BuSpar) stands out as unique among antianxiety drugs because of what factor? A) Increases the central nervous system (CNS) depression of alcohol and other drugs. B) Lacks muscle relaxant and anticonvulsant effects. C) Causes significant physical and psychological dependence. D) Rapidly absorbed from the gastrointestinal (GI) tract and metabolized in the liver.
Ans: B Feedback: Buspirone, a newer antianxiety agent, has no sedative, anticonvulsant, or muscle-relaxant properties, and its mechanism of action is unknown. However, it reduces the signs and symptoms of anxiety without many of the central nervous system effects and severe adverse effects associated with other anxiolytic drugs. Most of the antianxiety drugs are rapidly absorbed from the GI tract, metabolized in the liver, have a significant drugdrug interaction with alcohol and other drugs, and can result in psychological dependence.
10. An elderly patient has been taking zolpidem (Ambien) as a sleep aid for the past 2 months. On admission to the assisted-living facility, it is determined that the drug is no longer needed. What is an important nursing consideration concerning this drug? A) Hallucinations are common. B) The drug needs to be withdrawn gradually. C) Another anxiolytic will need to be substituted. D) Sundowning is common with withdrawal from this drug
Ans: B Feedback: It is important for the nurse to understand that zolpidem must be withdrawn gradually over a 2-week period after prolonged use. If chloral hydrate is stopped suddenly, it will result in serious adverse effects. Hallucinations and sundowning are not common with withdrawal of the drug. The prescriber and the patient would determine the need for chloral hydrate to be substituted for another anxiolytic
9. The nurse is caring for a resident in a long-term care facility who is African American with a history of an anxiety disorder. The patient is receiving oral lorazepam (Ativan) 2 mg t.i.d. When developing this patient's plan of care, what priority assessment will the nurse include? A) Depression B) Extreme sedation C) Phlebitis D) Nightmares
Ans: B Feedback: Special care should be taken when anxiolytic or hypnotic drugs are given to African Americans. About 15% to 20% of African Americans are genetically predisposed to delayed metabolism of benzodiazepines. As a result, they may develop high serum levels of these drugs, with increased sedation and an increased incidence of adverse effects. Depression is not a common adverse effect. Phlebitis can occur at injection sites but this patient is taking the medication orally. Nightmares occur during drug withdrawal.
11. Why would the nurse expect the patient with liver disease to receive a smaller dose of a benzo? A) Excretion of the drug relies on liver function. B) The drugs are metabolized extensively in the liver. C) They are lipid soluble and well distributed throughout the body. D) The drugs are well absorbed from the gastrointestinal tract.
Ans: B Feedback: The benzodiazepines are metabolized extensively in the liver. Patients with liver disease must receive a smaller dose and be monitored closely. Excretion is primarily through the urine. All of the answer options are true, but only the fact that the benzodiazepines are metabolized in the liver explains why a patient with liver disease would require smaller dosages.
14. The nurse is caring for a patient in intensive care unit receiving IV lorazepam (Ativan) to reduce anxiety related to mechanical ventilation. While injecting the medication the nurse notes a decrease in blood pressure and bradycardia. What is the nurse's priority action? A) Discontinue drug administration. B) Give the IV drug more slowly. C) Notify the patient's health care provider. D) Document the reaction to the drug.
Ans: B Feedback: The nurse's priority action is to slow the rate of injection because rapid injection of benzodiazepines can result in hypotension and bradycardia and can lead to cardiac arrest.
4. A nurse is discussing the use of alprazolam (Xanax) with a 68-year-old patient. What statement indicates that the patient has an understanding of the drug? A) When I stop having panic attacks, I can stop taking the drug. B) This drug will calm me down in about 30 minutes after I take it. C) One dose will keep me calm for about 24 hours. D) I am taking an increased dose because of my
Ans: B Feedback: The onset of alprazolam is about 30 minutes. The drug must be tapered after long-term use and the duration is approximately 4 to 6 hours. Elderly patients usually have a reduced dosage
28. The nurse evaluates teaching as effective when a patient taking a benzodiazepine states, A) I should always take the medication with meals. B) I should not stop taking this drug without talking to my health care provider first. C) I cannot take aspirin with this medication. D) I will have to take this medication for the rest of my life.
Ans: B Feedback: The patient makes a correct statement when saying the drug should not be stopped without talking to the health care provider first because withdrawal of benzodiazepines require careful monitoring and should be gradually withdrawn. Medications do not have to be taken with food, aspirin is not contraindicated, and the medication need only be taken while the condition being treated continues. Patients with anxiety may only need the medication for a few weeks whereas those with a seizure disorder may take it for longer periods of time.
23. The nurse is caring for a patient who is taking a benzodiazepine. The nurse knows that caution should be used when administering a benzodiazepine to the elderly because of what possible adverse effect? A) Acute renal failure B) Unpredictable reactions C) Paranoia D) Hallucinations
Ans: B Feedback: Use benzodiazepines with caution in elderly or debilitated patients because of the possibility of unpredictable reactions and in patients with renal or hepatic dysfunction, which may alter the metabolism and excretion of these drugs, resulting in direct toxicity. Dosage adjustments usually are needed for such patients. Acute renal failure, paranoia, and hallucinations are not commonly related to therapy with these medications in the elderly.
13. What would the nurse assess for when benzodiazepines are abruptly stopped? A) Urinary retention and change in sexual functioning B) Dry mouth, constipation, nausea, and vomiting C) Nausea, headache, vertigo, malaise, and nightmares D) In most cases nothing significant
Ans: C Feedback: Abrupt cessation of these drugs may lead to a withdrawal syndrome characterized by nausea, headache, vertigo, malaise, and nightmares. When benzodiazepines are stopped abruptly the likelihood of withdrawal symptoms increases with the length of time the patient took the medication. Urinary retention, change in sexual functioning, dry mouth, constipation, nausea, and vomiting are all common adverse effects of the medications classified as benzodiazepines.
8. A patient arrives at the emergency room after attempting suicide by taking an entire bottle of diazepam. What antidote will the nurse most likely administer? A) Phenobarbital (Luminal) B) Dexmedetomidine (Precedex) C) Flumazenil (Romazicon) D) Ramelteon (Rozerem)
Ans: C Feedback: Flumazenil is an antidote to benzodiazepine overdose and is administered to reverse the effects of benzodiazepines when used for anesthesia. Phenobarbital, a barbiturate, would further depress the body functions of this patient. Dexmedetomidine is a new hypnotic drug used in the intensive care unit for mechanically ventilated patients. Ramelteon is also new; it is used as a hypnotic. Adverse effects of this drug include depression and suicidal ideation.
20. Hypnotic drugs are used to aid people in falling asleep. What physiological system does a hypnotic act on to be effective in helping a patient to sleep? A) Limbic system B) Sympathetic nervous system C) Reticular activating system D) Lymph system
Ans: C Feedback: Hypnotics are used to help people fall asleep by causing sedation. Drugs that are effective hypnotics act on the reticular activating system and block the brain's response to incoming stimuli. Hypnosis, therefore, is the extreme state of sedation, in which the person no longer senses or reacts to incoming stimuli. The other options are incorrect.
6. The nurse is caring for a 36-year-old man who experienced a seizure 30 minutes before coming into the emergency room, where he begins to have another. What barbiturate has the fastest onset and would be most appropriate to give to the patient to quickly stop the seizure? A) Amobarbital (Amytal Sodium) B) Mephobarbital (Mebaral) C) Phenobarbital (Luminal) D) Secobarbital (Seconal)
Ans: C Feedback: Phenobarbital's onset is between 10 and 60 minutes, depending on the route administered, and most likely this would be given to the patient. Amobarbital is given for convulsions and the onset is between 15 and 60 minutes. Mephobarbital's onset is between 30 and 60 minutes. Secobarbital is given for convulsive seizures of tetanus and has an onset of 1 to 4 hours.
2. A nurse is caring for a 4-year-old child who is receiving a barbiturate. What common adverse effect would the nurse assess for? A) Decrease in respirations B) Vomiting C) Excitability D) Dry mucous membranes
Ans: C Feedback: The barbiturates, being older drugs, have established pediatric dosages. These drugs must be used with caution because of the often unexpected responses. Children must be monitored very closely for central nervous system (CNS) depression and excitability. The most common adverse effects are related to general CNS depression. Other CNS effects may include drowsiness, somnolence, lethargy, ataxia, vertigo, a feeling of a hangover, thinking abnormalities, paradoxical excitement, anxiety, and hallucinations. Alteration in respirations and dried mucous membranes are adverse effects of antihistamines, which can be given to calm children or induce sleep. Vomiting could occur with the use of paraldehyde due to the unpleasant taste and odor of the drug.
5. A nurse is about to administer a parenteral benzodiazepine to a female patient in the hospital before the performance of a procedure. What is the priority nursing action before administration of the drug? A) Make sure that the side rails are up and the bed is in the lowest position. B) Close the blinds and ensure appropriate room temperature for the patient. C) Help the patient out of bed to the bathroom and encourage her to void. D) Ask all visitors to leave the room and remain in the waiting area
Ans: C Feedback: The priority action would be to help the patient up to void. After the medication is administered the patient should not get out of bed because of possibly injury due to drowsiness. Safety should always be the priority concern. After administration of the drug the nurse would ask visitors to leave before beginning the procedure, make the room conducive to rest and sleep, and make sure that both side rails are up and the bed is in the lowest position.
15. For what purpose would the nurse choose to administer a hypnotic instead of another classification of antianxiety drug? A) Treating insomnia B) Treating seizure disorder C) Treating panic attach D) Treating confusion and agitation
Ans: D Feedback: Hypnotics are used to help people fall asleep by causing sedation. Drugs that are effective hypnotics act on the reticular activating system (RAS) and block the brain's response to incoming stimuli. Hypnotics would not be the most effective drugs to treat seizure disorders, panic attack, or confusion with agitation.
26. An older adult African American patient comes to the clinic and is diagnosed with generalized anxiety disorder (GAD). The physician orders oral flurazepam 30 mg. What is the nurse's priority action? A) Teach the patient about the prescribed medication. B) Administer the first dose of medication. C) Tell patient to take first dosage after driving home. D) Talk to the physician about the dosage.
Ans: D Feedback: If an anxiolytic or hypnotic agent is the drug of choice for an African American patient, the smallest possible dose should be used, and the patient should be monitored very closely during the first week of treatment. Dosage adjustments are necessary to achieve the most effective dose with the fewest adverse effects. In addition, older adults also require careful titration of dosage. Older patients may be more susceptible to the adverse effects of these drugs, from unanticipated central nervous system (CNS) adverse effects including increased sedation, dizziness, and even hallucinations. Dosages of all of these drugs should be reduced and the patient should be monitored very closely for toxic effects and to provide safety measures if CNS effects do occur. As a result, the priority action is to talk to the physician about the dosage. The other actions may be appropriate after a proper dosage is ordered.
3. A nurse is caring for a 9-year-old patient and has received an order for diazepam (Valium) 10 mg given orally q.i.d. What is the nurse's priority action? A) Perform hand hygiene and prepare the drug. B) Send the order to the hospital pharmacy. C) Determine when to administer the first dose. D) Call the physician and question the order.
Ans: D Feedback: The first action of the nurse would be to call the physician and question the order. The normal oral dosage for a pediatric patient is 1 to 2.5 mg t.i.d. or q.i.d. The ordered dose would be unsafe for this patient. If the dosage was changed and the correct amount administered, the nurse would order the medication from the pharmacy if necessary and determine what time to start the medication. She would then wash her hands in preparation for administering the medication, but not until obtaining an appropriate dosage of medication
25. The nurse is caring for a patient who has not been able to sleep. The physician orders a barbiturate medication for this patient. What adverse effect should the nurse teach the patient about? A) Double vision B) Paranoia C) Tinnitus D) Thinking abnormalities
Ans: D Feedback: The most common adverse effects are related to general central nervous system (CNS) depression. CNS effects may include drowsiness, somnolence, lethargy, ataxia, vertigo, a resembling a hangover, thinking abnormalities, paradoxical excitement, anxiety, and hallucinations. Barbiturate drugs generally do not cause double vision, paranoia, or tinnitus.
21. A patient presents at the emergency department with respiratory depression and excessive sedation. The family tells the nurse that the patient has been taking medication throughout the evening and gives the nurse an almost empty bottle of benzodiazepines. What other adverse effects would the nurse assess this patient for? A) Seizures B) Tachycardia C) Headache D) Coma
Ans: D Feedback: Toxic effects of benzodiazepines include excessive sedation, respiratory depression, and coma. Flumazenil (Anexate) is a specific antidote that competes with benzodiazepines for benzodiazepine receptors and reverses toxicity. Seizures, tachycardia, and headache would not normally be associated with benzodiazepine toxicity.
24. A 72-year-old patient presents at the emergency department with respiratory depression and excessive sedation. The family tells the nurse that the patient has been taking medication throughout the evening. The nurse suspects benzodiazepine overdose and would expect what drug to be ordered? A) Valium B) Phenergan C) Hydroxyzine D) Flumazenil
Ans: D Feedback: Toxic effects of benzodiazepines include excessive sedation, respiratory depression, and coma. Flumazenil is an antidote for the benzodiazepines. Hydroxyzine is an antihistamine with anticholinergic effects and would not be appropriate for this patient. Valium would enhance the effects of benzodiazepines. Phenergan is not indicated for this patient; it is similar in actions to hydroxyzine.
Barbiturates adverse effects
CNS Depression Physical Dependency Drowsiness Somnolence Lethargy Ataxia Vertigo Nausea Vomiting Constipation
7. What anxiolytic drugs would be given to a premenopausal patient who is a registered nurse planning to return to work at the hospital after anxiety is controlled? A) Alprazolam (Xanax) B) Buspirone (BuSpar) C) Diazepam (Valium) D) Clorazepate (Tranxene)
This is what they prescribed for my mom. Ans: B Feedback: Buspirone is a newer anxiolytic drug that does not cause sedation or muscle relaxation. It is preferred when the patient needs to be alert such as when driving or working. Alprazolam, diazepam, and clorazepate are benzodiazepines, which cause drowsiness, sedation, depression, lethargy, confusion, and decreased mental alertness. It would be unsafe for a nurse to function in her role while taking one of these drugs.
Other anxiolytic and hypnotics drugs
•Antihistamines (promethazine [Promethegan], diphenhydramine [generic]): Preoperative medications and postoperative to decrease the need for narcotics •Buspirone (generic): Reduces the signs and symptoms of anxiety without severe CNS and adverse effects •Dexmedetomidine (Precedex): Sedation of intubated and mechanically ventilated patients •Eszopiclone (Lunesta): Insomnia -Meprobamate (generic): Acute anxiety, up to 4 months •Ramelton (Rozerem), tasimelteon (Hetiloz): Melatonin receptor agonists •Suvorexant (Belsomra): Orexin receptor antagonist •Zaleplon (Sonata) and zolpidem (Ambien): Short-term treatment of insomnia
Barbiturates drug interactions
•Increase CNS depression when given with alcohol, antihistamines, and other tranquilizers •Altered response to phenytoin •MAO cause increase serum levels and effect •Decrease effectiveness of the following drugs: anticoagulants, digoxin, tricyclic antidepressants, corticosteroids and oral contraceptives
Barbiturates contraindications
•Previous history of addiction to sedative-hypnotic drugs •Latent or manifest porphyria •Marked hepatic impairment or nephritis •Respiratory distress or severe respiratory dysfunction •Pregnancy