PREPU (UNFINISHED) Chapter 20: Antianxiety Drugs

12 of 20 The nurse should include which instruction about antianxiety medications and drug interactions in the teaching plan? • "One to three alcoholic beverages a day may help you feel more relaxed while taking antianxiety drugs." • "Consult your healthcare provider about increasing the dose of digoxin while taking antianxiety drugs." • "Avoid driving or operating heavy machinery when taking tricyclic antidepressants and starting antianxiety drugs." • "If taking pain medications, you may need to increase the doses for effective pain relief while taking antianxiety medications."

• "Avoid driving or operating heavy machinery when taking tricyclic antidepressants and starting antianxiety drugs." Explanation: While taking antianxiety medications, the client should be taught about several interacting drugs and the effects of their interactions. Tricyclic antidepressants can increase the risk for sedation and respiratory depression; therefore, it is advisable to tell the client to avoid driving and operating heavy machinery when beginning these medications. Antianxiety drugs increase the risk for digitalis toxicity; therefore, the dose of digoxin would not be increased. Alcohol can increase the risk for central nervous system depression or convulsions. Analgesics can increase the risk for central nervous depression; therefore, the doses would not likely be increased.

8 of 20 A client's medication regimen for treatment of anxiety has been changed from a benzodiazepine to buspirone (BuSpar). The client asks the nurse what makes this medication safer than the benzodiazepine the client has taken. What is the nurse's best response? • "It produces muscle relaxant effects to decrease back pain." • "It will not produce sedation like benzodiazepines." • "It provides you with a sleep additive to decrease insomnia." • "It produces anticonvulsant action to prevent convulsions."

• "It will not produce sedation like benzodiazepines." Explanation: Buspirone will not produce sedation. Compared with the benzodiazepines, buspirone (BuSpar) lacks muscle relaxant and anticonvulsant effects; does not cause sedation or physical or psychological dependence; does not increase the CNS depression of alcohol and other drugs; and is not a controlled substance.

18 of 20 A client's medication regimen for treatment of anxiety has been changed from a benzodiazepine. The client asks the nurse what likely prompted the health care provider to change the medication. What is the nurse's best response? • "Your doctor may have been worried about the possibility of convulsions." • "Your doctor may have been concerned about causing depression." • "Long-term use of benzodiazepines can cause insomnia." • "Long-term use of benzodiazepines can result in dependency."

• "Long-term use of benzodiazepines can result in dependency." Explanation: Although benzodiazepines are effective anxiolytics, long-term use is associated with concerns over tolerance, dependency, withdrawal, lack of efficacy for treating the depression that often accompanies anxiety disorders, and the need for multiple daily dosing with some agents. They do not cause insomnia, convulsions, or depression.

4 of 5 A hospitalized client asks the nurse why the health care provider prescribed an anxiolytic medication. What is the nurse's best response? • "This type of medication is typically prescribed to treat excess anxiety that interferes with daily activities." • "Anxiolytics are prescribed to treat anxiety and can be purchased without a prescription after discharge." • "Anxiolytic drugs are different from antianxiety drugs, because they work without a tranquilizing effect." • "An anxiolytic, such as alprazolam (Xanax), is usually prescribed for long-term anxiety disorders."

• "This type of medication is typically prescribed to treat excess anxiety that interferes with daily activities." Explanation: Drugs used to treat anxiety are called antianxiety, or anxiolytic, drugs. Long-term use of benzodiazepines, such as Xanax, can result in physical or psychological dependence. Due to the risk of dependence, benzodiazepines are used for short-term anxiety relief. Due to the risk of dependence, anxiolytics are classified as schedule IV contolled substances. Therefore, anxiolytics require a prescription. Anxiolytic drugs exert their tranquilizing effect by blocking certain neurotransmitter sites.

1 of 20 A client received lorazepam intravenously at 0900. The nurse should maintain the client on bedrest until approximately what time? • 1500 • 1200 • 1330 • 1030

• 1200 Explanation: Patients who receive parenteral benzodiazepines should be monitored in bed for a period of at least 3 hours. Thus the patient would be allowed out of bed at approximately 12 PM.

After administering an antianxiety drug, the nurse obtains the client's blood pressure. The nurse withholds the next dose if the client's systolic blood pressure has dropped by which value? • 20 mm Hg. • 15 mm Hg. • 10 mm Hg. • 5 mm Hg.

• 20 mm Hg. Explanation: If the client's systolic pressure has dropped 20 mm Hg, the nurse withholds the drug due to increased risk for fall and notifies the health care provider. The lesser values of 5 to 15 mm Hg can indicate normal position change or activity. Question 4

14 of 20 The nurse should notify the healthcare provider for which client to clarify a prescription of lorazepam (Ativan)? • A client who is post-menopausal • A client 23 years of age with an allergy to alprazolam (Xanax) • A client 67 years of age with acute narrow-angle glaucoma • A client 52 years of age with a history of hypertension

• A client 67 years of age with acute narrow-angle glaucoma Explanation: Administering antianxiety drugs is contraindicated in clients with known hypersensitivities, psychoses, and acute narrow-angle glaucoma. Xanax and Ativan are both benzodiazepines. Cross sensitivity is likely to occur. Benzodiazepines are contraindicated during pregnancy (category D) and labor. Pregnancy is not a likely concern for the post-menopausal client. Hypertension is not a contraindication to benzodiazepine use.

14 of 20 Which client should the nurse expect to receive a lower-than-usual dose of benzodiazepines? • A client whose anxiety is due to pain caused by gallstones. • A client with alcoholic liver disease • A client who is six months post-gastrectomy. • A client who has irritable bowel syndrome.

• A client with alcoholic liver disease Explanation: The benzodiazepines are metabolized extensively in the liver. Patients with liver disease must receive a smaller dose and be monitored closely. Gastrointestinal and biliary health problems would not necessitate a lower dose.

A client has been admitted to the emergency department in convulsions and been prescribed 200 mg amobarbital (Amytal sodium) IV STAT. What is the nurse's best action? • Establish central IV access and administer the medication • Administer the medication and monitor the client's status closely • Question the provider about the route of the medication • Confirm the dose with the prescriber or a pharmacist

• Administer the medication and monitor the client's status closely Explanation: The prescribed dose falls within recommended parameters for indication, dose and route. The nurse should administer the medication and monitor the client closely. There is no requirement that the medication be administered by central line, and not peripherally. Question 16

After administering diazepam (Valium) intramuscularly, what is the nurse's best action? • Ask the nursing assistant to assess the site for erythema or bruising. • Ask the nursing assistant to inform you of the client's respiratory rate when taking the next scheduled set of vital signs. • Instruct the nursing assistant to check for signs of hypertension. • Advise the client to remain in bed for at least 30 minutes.

• Advise the client to remain in bed for at least 30 minutes. Explanation: After parenteral administration of antianxiety agents, the client should be observed closely for at least 3 hours. The client is kept lying down (when possible) for 30 minutes to 3 hours after the drug is given. It is not appropriate for the LPN to delegate assessments to a nursing assistant, such as assessing the injection site or assessing for signs of hypertension. After parenteral administration of antianxiety agents, the client is more likely to experience hypotension. Frequent assessment of vital signs is important after injection of antianxiety medications; therefore, waiting until the next scheduled set of vital signs is not the best action. Question 15

The nurse is caring for a client treated with flumazenil (Anexate) for benzodiazepine toxicity. After administering flumazenil what should the nurse carefully assess for? • Hypotension, dysrhythmias, and cardiac arrest • Agitation, confusion, and seizures • Cerebral hemorrhage and dystonia • Hypertension and renal insufficiency

• Agitation, confusion, and seizures Explanation: Administration of flumazenil blocks the action of benzodiazepines. If the client 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. Question 19

3 of 5 A nurse is caring for a client who is receiving flumazenil to combat benzodiazepine toxicity. Which adverse effect can be caused by flumazenil? • Agitation, confusion, and seizures • Hypotension, dysrhythmias, and cardiac arrest • Hypertension and renal insufficiency • Cerebral hemorrhage and dystonia

• Agitation, confusion, and seizures Explanation: Adverse effects of flumazenil include precipitation of acute benzodiazepine withdrawal symptoms, agitation, confusion, and seizures.

5 of 20 A client reports constant nervousness, worry, and tension. These signs are indicative of which disorder? • Depression • Anxiety • Neurosis • Psychosis

• Anxiety Explanation: Anxiety is characterized by nervousness, tension, and worry. When anxiety is severe or prolonged and interferes with daily living, it is called an anxiety disorder.

A group of nursing students are reviewing information about antianxiety drugs. The students demonstrate understanding of the information when they identify which as another name for this group of drugs? • Anesthetics • Anxiolytics • Opioids • NSAIDs

• Anxiolytics Explanation: Antianxiety drugs are also referred to as anxiolytics. Opioids are narcotic drugs used in the treatment of acute pain; NSAIDs are nonsteroidal anti-inflammatory medications used in treatment of chronic pain such as arthritis; and anesthetics are medications used to induce unconsciousness for surgery or administered locally to block pain during a procedure such as suturing. Question 2

The nurse obtains the following vital signs on a client: BP 160/85, P 90, RR 24. The client is recently divorced and reports taking alprazolam (Xanax) for the past seven weeks but stopped the medication yesterday. What is the nurse's first action? • Advise the client that increased blood pressure is an expected finding after discontinuing Xanax. • Document the client's vital signs in the electronic medical record and advise the charge nurse. • Notify the health care provider of the abnormal vital signs. • Ask the client about experiencing increased anxiety, difficulty concentrating, or tremors.

• Ask the client about experiencing increased anxiety, difficulty concentrating, or tremors. Explanation: The nurse needs to further assess the cause of the client's elevated vital signs. Because the client has been taking an antianxiety medication and has recently discontinued the drug, the client may be suffering from withdrawal symptoms. Symptoms of benzodiazepine withdrawal include increased anxiety, difficulty concentrating, tremors, and sensory disturbances. The onset of withdrawal symptoms usually occurs within one to 10 days after discontinuing the drug. Increased blood pressure is not a normal, or expected, finding after discontinuing Xanax and may be a sign of increased anxiety and withdrawal. The nurse should further assess for signs of withdrawal, then notify the health care provider. Documenting the client's vital signs and advising the charge nurse is appropriate, but the first action is to further assess the cause of abnormal vital signs. Question 14

5 of 5 The nurse is assessing a client in the clinic who reports a new onset of anxiety. What should be the nurse's first action? • Coach the client in taking short, shallow breaths at a rate of 20-30 breaths per minute. • Explain to the client that being in a clinic setting can lead to increased anxiety. • Advise the client of the importance of remembering the exact date and time the anxiety began. • Ask the client to rate the anxiety level using a 0-10 scale.

• Ask the client to rate the anxiety level using a 0-10 scale. Explanation: Anxiety is a subjective feeling, therefore asking the client to rate the anxiety level using a 0-10 scale is an appropriate method used to assess a subjective feeling, just as nurses would do when assessing pain. When in a state of mild to moderate anxiety, clients may be able to give a reliable history of their illness. Though being in the clinic may lead to increased anxiety, the nurse needs to assess first, since this is the initial step of the nursing process. The client's anxiety may or may not be due to being in the clinic. The nurse would not know the cause of anxiety without assessing the level of anxiety and first collecting a history. Short, shallow breaths at an increased rate are a manifestation of anxiety, which can lead to hyperventilation. The nurse should instead coach the client in taking slow, deep breaths.

17 of 20 The nurse is caring for an older adult in the long-term care facility who has begun to display signs of anxiety and insomnia. What is the priority nursing action? • Call the provider and request an antianxiety drug order. • Increase the client's social time, encouraging interaction with others. • Suggest the family visit more often to reduce the resident's stress level. • Assess the client for physical problems.

• Assess the client for physical problems. Explanation: The client should be screened for physical problems, neurological deterioration, or depression, which could contribute to the insomnia or anxiety. Only after physical problems are ruled out would the nurse consider nondrug measures such as increased socialization with other residents or family members. If nothing else is effective, pharmacological intervention may be necessary.

A client presents at the emergency department with respiratory depression and excessive sedation. The family tells the nurse that the client has been taking medication throughout the evening. What would the nurse suspect? • Hypnotic overdose • Benzodiazepine overdose • Sedative overdose • Anti-anxiety overdose

• Benzodiazepine overdose Explanation: 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. Question 7

A 75-year-old client is brought to the emergency department by the family. The family relates that the client has confusion, seizures, and abnormal perception of movement. When the nurse looks at the medication that the family has brought to the ED, the nurse discovers that twice the number of tablets are missing from the vial as there should be if the prescription orders were being followed. What should the nurse suspect is wrong with this client? • Benzodiazepine toxicity • Antihypertensive toxicity • Sedative toxicity • Analgesic toxicity

• Benzodiazepine toxicity Explanation: Common manifestations 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.

2 of 5 A benzodiazepine will be prescribed for a client. The nurse knows that which statement regarding benzodiazepines is correct? • Benzodiazepine administration does not cause physical dependence. • Benzodiazepines are safer than barbiturates for managing anxiety. • Benzodiazepines can be used in the management of psychoses. • Benzodiazepines are Pregnancy Risk Category B drugs.

• Benzodiazepines are safer than barbiturates for managing anxiety. Explanation: Benzodiazepines are Pregnancy Risk Category D: there is risk for fetal adverse effects but these drugs can be used if the possible benefits are greater than the potential risk. Benzodiazepines are much safer than barbiturates, and have largely replaced barbiturates in the management of anxiety. Benzodiazepines are contraindicated in psychoses, and can cause both physical and psychological dependence.

3 of 20 When preparing to administer an antianxiety agent, the nurse understands that the drug exerts its anxiolytic effect by acting on the brain's serotonin receptors. The nurse is most likely administering which drug? • Hydroxyzine • Oxazepam • Buspirone • Lorazepam

• Buspirone Explanation: Buspirone (BuSpar) exerts its anxiolytic effect by acting on the brains serotonin receptors. Lorazepam is a benzodiazepine that exerts its effect by potentiating the effects of gamma-aminobutyric acid. Oxazepam is a benzodiazepine that exerts its effect by potentiating the effects of gamma-aminobutyric acid. Hydroxyzine exerts its anxiolytic effect by acting on the hypothalamus and brainstem reticular formation.

1 of 5 A nurse is reviewing information about anxiolytics. Which anxiolytics would the nurse identify as the safest to use in older adult clients? • Lorazepam • Doxepin • Buspirone • Hydroxyzine

• Buspirone Explanation: Buspirone is a safe choice for the older adult client with anxiety because it does not cause excessive sedation and the risk of falling is not as great. Lorazepam is a benzodiapine used for short-term anxiety and has increased risk for falls due to dizziness and lightheadedness. Doxepin is a nonbenzodiapine much like buspirone, however, it is used for those severely ill. Hydroxyzine is also a nonbenzodiapine causing drowsiness and involuntary motor activity increasing the risk for falls.

5 of 20 After teaching a group of nursing students about antianxiety drugs, the instructor determines that the teaching was successful when the students identify which as an example of a nonbenzodiazepine? Select all that apply. • Doxepin • Lorazepam • Buspirone • Diazepam • Hydroxyzine

• Buspirone • Hydroxyzine • Doxepin Explanation: Buspirone is an example of a nonbenzodiazepine. Doxepin is an example of a nonbenzodiazepine. Hydroxyzine is an example of a nonbenzodiazepine. Diazepam is a benzodiazepine. Lorazepam is a benzodiazepine.

Which drug used to treat anxiety would be appropriate for a client who is a school teacher and is concerned about feeling sedated at work? • Buspirone (BuSpar) • Diazepam (Valium) • Lorazepam (Ativan) • Alprazolam (Xanax)

• Buspirone (BuSpar) Explanation: Buspirone does not cause as much sedation and functional impairment as lorazepam, alprazolam, and diazepam. However, it can cause dizziness, nausea, headache, nervousness, lightheadedness, or excitement. Question 8

Many anti-anxiety drugs pose risks for abuse and physical dependence. The nurse knows that which of the following drugs has the least risk for physical dependence? • Buspirone (BuSpar) • Chlorazepate (Tranxene) • Chlordiazepoxide (Librium) • Lorazepam (Ativan)

• Buspirone (BuSpar) Explanation: Chlordiazepoxide, lorazepam, and chlorazepate are benzodiazepines and have potential for abuse and physical dependence. Buspirone has the least potential for abuse. Question 11

7 of 20 A benzodiazepine will be prescribed for a client. The nurse knows that which drug is a benzodiazepine? • Doxepin (Sinequan) • Hydroxyzine (Vistaril) • Buspirone (BuSpar) • Chlordiazepoxide (Librium)

• Chlordiazepoxide (Librium) Explanation: Chlordiazepoxide is a benzodiazepine. Buspirone, doxepin, and hydroxyzine are nonbenzodiazepine antianxiety drugs.

3 of 5 The nurse and the client are discussing various drugs for management of anxiety. The client asks, "How do these drugs work?" The nurse knows that interaction with the central nervous system neurotransmitter gamma-aminobutyric acid (GABA) is the mechanism of which drug? • Hydroxyzine (Vistaril) • Doxepin (Sinequan) • Meprobamate (Equanil, Miltown) • Diazepam (Valium)

• Diazepam (Valium) Explanation: GABA is a major inhibitory neurotransmitter in the central nervous system. Benzodiazepines such as diazepam increase the inhibitory effect of GABA. Doxepin, hydroxyzine, and meprobamate do not affect GABA neurotransmission.

13 of 20 The nurse knows that the health care provider may lower the dose of morphine sulfate when given with diazepam (Valium). Why? • Morphine sulfate potentiates the diazepam. • The combination of lorazepam and morphine may cause severe hypertension. • Diazepam potentiates the morphine sulfate. • Combining these two drugs may cause severe nausea.

• Diazepam potentiates the morphine sulfate. Explanation: Antianxiety drugs have sedative action; when combined with an opioid, they allow a lowering of the opioid dosage because they have the ability to potentiate (increase the effect of) the sedative action of the opioid. They may cause hypotension when used together, and will not cause severe nausea when used together.

8 of 20 A client has been taking diazepam (Valium) for several months and remarks to the nurse it takes more and more of the medication to maintain the drug's effect. The nurse recognizes this response as what? • Drug tolerance • Drug toxicity • Drug withdrawal • Drug dependence

• Drug tolerance Explanation: Continued administration of a benzodiazepine will lead to drug tolerance: a greater dose of drug is required to produce the effect originally obtained with a lower dose. Drug toxicity would involve enhanced adverse drug effects. Drug dependence can develop with long-term use of a benzodiazepine but is not defined as loss of effect. Drug withdrawal is a syndrome that occurs with abrupt discontinuation of drug in a person who has developed physical dependence.

11 of 20 The nurse is teaching the client about preventing constipation while on alprazolam (Xanax). What is the nurse's best response? • Increase the intake of citrus fruit juices. • Eat high-fiber foods. • Decrease water intake. • Eliminate daily jogging routine.

• Eat high-fiber foods. Explanation: The nurse can advise the client taking antianxiety drugs to eat high-fiber foods, increase fluid intake, and exercise (if his condition permits) in order to prevent constipation. Because consuming grapefruit juice can interfere with enzyme activity and effectiveness of some antianxiety drugs, increasing the intake of fruit juices is not the best response among all the answer options.

A nurse is caring for a client with complaints of constipation after the administration of antianxiety drugs. Which would be appropriate for the nurse to include in the client's plan of care? Select all that apply. • Offer meals rich in fiber • Encourage increased fluid intake • Increase the intake of fruits • Suggest use of antacid • Reduce the dosage.

• Encourage increased fluid intake • Increase the intake of fruits • Offer meals rich in fiber Explanation: The nursing interventions involved in caring for clients with complaints of constipation after administration of antianxiety drugs include encouraging increased fluid intake, increasing the intake of fruits and vegetables, and offering meals rich in fiber. Administering oral antianxiety medications with meals will help decrease risk of GI upset but has little effect on constipation. Use of an antacid or a reduced dosage will not help to counter constipation. Question 5

1 of 20 Which action by the new nurse would alert the charge nurse that more education is needed for the new nurse, after administering an anxiolytic to a client? • Place the call light within reach • Having the client walk to the bathroom • Raise the side rails • Dim the lights

• Having the client walk to the bathroom Explanation: Having the client walk to the bathroom would be appropriate before administering the drug to reduce the client's risk for injury. Raising the side rails would be appropriate after administering an anxiolytic. Placing the call light within reach would be appropriate after administering an anxiolytic. Dimming the lights would be appropriate after administering an anxiolytic.

A client who has taken diazepam for several months has developed physical dependence. The nurse has set up a schedule to taper drug doses to avoid a withdrawal syndrome. Which symptom would indicate that a withdrawal syndrome has occurred? Select all that apply. • Constipation • Tremor • Headache • Increased anxiety • Dry skin

• Headache • Increased anxiety • Tremor Explanation: Tremor, increased anxiety, and headache are symptoms of benzodiazepine withdrawal. Sweating rather than dry skin is a symptom of withdrawal. Constipation does not occur with withdrawal. Question 13

10 of 20 The nurse is reviewing the medication chart of an 82-year-old man who has recently moved to a long-term care facility. The record reveals that the man takes 1 to 2 mg of lorazepam bid prn. The nurse should recognize what consequence of this resident's drug regimen? • Anorexia • Cold intolerance • Risk for paradoxical aggression • Increased risk for falls

• Increased risk for falls Explanation: In a systematic review of medications as risk factors for falls, it was found that one of the main group of drugs associated with this risk were benzodiazepines. Benzodiazepines are not associated with cold intolerance, anorexia, or aggression.

A review of a client's history reveals that the client uses kava for stress relief. When teaching the client about this herb, the nurse would include a discussion about which as a serious consequence associated with its use? • Liver failure • Kidney failure • Heart failure • Stroke

• Liver failure Explanation: Kava-containing products have been associated with liver-related injuries including hepatitis, cirrhosis, and liver failure. The FDA has issued alerts regarding Kava and its effects on the liver, however, none has been issued for kidney failure, heart failure, or stroke. Question 3

2 of 20 After teaching a class on antianxiety drugs, the instructor determines that the teaching was successful when the class identifies which as a controlled substance by DEA regulations? • Buspirone • Doxepin • Lorazepam • Hydroxyzine

• Lorazepam Explanation: Benzodiazepines like lorazepam are classified as a schedule IV controlled substances by DEA regulations. Buspirone is a nonbenzodiaepine with less physical dependence. This is the same for doxepin and hydroxyzine.

12 of 20 An older adult is prescribed an anti-anxiety drug. The nurse knows that which of the following statements regarding anxiety management in older adults is correct? • Buspirone is not recommended for use in older adults. • Lorazepam (Ativan) is the best choice of benzodiazepines for older adults. • Anti-anxiety drugs are metabolized more rapidly in older adults compared to younger adults. • Anti-anxiety drug doses for older adults are higher than those for younger adults.

• Lorazepam (Ativan) is the best choice of benzodiazepines for older adults. Explanation: Lorazepam is the best benzodiazepine for older adults. It does not give rise to active metabolites that accumulate and produce sustained adverse effects. Buspirone also is safe for older adults. It produces less sedation and less risk for falls. Anti-anxiety drug doses initially should be lower than those for younger adults. Older adults inactivate drugs more slowly.

13 of 20 A client who has claustrophobia is scheduled for an magnetic resonance imaging for the investigation of an abdominal mass. The nurse should anticipate what pre-medication order? • Eszopiclone 1 mg PO • Suvorexant 10 mg PO • Lorazepam 2 mg PO • Ramelteon 8 mg PO

• Lorazepam 2 mg PO Explanation: Benzodiazepines are often prescribed to relieve pre-procedure anxiety. Eszopiclone, ramelteon and suvorexant are hypnotics which would induce several hours of sleep, which would be problematic.

3 of 20 A client is prescribed hydroxyzine. The nurse would be alert for the development of which effect early on? • Inflammation of the mouth • Abdominal cramping • Inflamed mucous membranes • Mild drowsiness

• Mild drowsiness Explanation: The nurse should monitor for mild drowsiness early on with the administration of hydroxyzine. Inflamed mucous membranes or inflammation of the mouth suggests a fungal superinfection of the oral cavity after the administration of an antibiotic such as penicillin. Abdominal cramping is a symptom of a bacterial superinfection in the bowel after the administration of an antibiotic. Inflammation of the mouth is also an adverse effect of sulfonamides.

17 of 20 A nurse is caring for a 4-year-old child who is receiving a barbiturate. What assessment should the nurse prioritize? • Cardiac monitoring • Monitoring for agitation or restlessness • Assessment of deep tendon reflexes • Hydration status

• Monitoring for agitation or restlessness Explanation: 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. Cardiac effects are less common and hydration status is not normally affected. Deep tendon reflexes would only be affected in cases of extreme CNS depression.

11 of 20 The herbal preparation kava is suggested to have anti-anxiety action. People using this preparation must be advised that hepatotoxicity can be an adverse effect. The nurse knows that an alternate name for kava is what? • Valerian • Ginkgo biloba • Comfrey • Piper methysticum

• Piper methysticum Explanation: Kava has several names, including piper methysticum. Users must be vigilant for signs of decreased liver function.

4 of 20 A nurse determines the possibility of benzodiazepine toxicity based on assessment of which adverse effect? • Muscle pain • Severe headache • Abdominal pain • Respiratory depression

• Respiratory depression Explanation: Benzodiazepine toxicity causes sedation, respiratory depression, and coma. Abdominal pain, severe headache, and muscle pain are not symptoms of benzodiazepine toxicity.

15 of 20 The nurse is caring for a client who experiences anxiety and insomnia. The client visits the provider and is prescribed lorazepam. When developing the plan of care, what would be an appropriate nursing diagnosis related to effects of the drug? • Ineffective Tissue Perfusion related to vasoconstriction • Chronic Confusion related to decreased arousal • Risk for injury related to central nervous system (CNS) effects. • Fear related to rebound effects following therapy

• Risk for injury related to central nervous system (CNS) effects. Explanation: The most appropriate nursing diagnosis related to adverse effects of the drug is risk for injury related to CNS effects because benzodiazepines can have many CNS adverse effects. There is no plausible risk of ineffective tissue perfusion or fear. CNS effects may have temporary effect of cognition, but this would not become chronic.

10 of 20 Diazepam (Valium) is prescribed for a client. What are some possible adverse effects of diazepam? Select all that apply. • Increased salivation • Restlessness • Sedation • Hypothyroidism • Disorientation

• Sedation • Restlessness • Disorientation Explanation: Benzodiazepines usually cause central nervous system depression, resulting in sedation and disorientation. They can also, however, cause paradoxical central nervous system stimulation, resulting in restlessness. Benzodiazepines cause dry mouth rather than excess salivation. Benzodiazepines do not affect thyroid function.

4 of 5 Three days after discontinuing diazepam with medical guidance, an older adult continues to demonstrate impaired memory and confusion. The nurse should consider what possible explanation for the client's current status? • The client may have been experiencing a hypersensitivity to the drug, rather than an adverse effect. • Benzodiazepines can occasionally cause permanent alterations in personality and level of consciousness. • The client may have decreased liver function. • The adverse effects of benzodiazepines can persist for several days after stopping the drug.

• The adverse effects of benzodiazepines can persist for several days after stopping the drug. Explanation: Both therapeutic effects and adverse effects of diazepam are more likely to occur after 2 or 3 days of therapy than initially. Such effects accumulate with chronic usage and persist for several days after the drug is discontinued. Hypersensitivity and decreased liver function are unlikely. Benzodiazepines do not cause permanent changes in cognition.

A 35-year-old has been prescribed lorazepam for the treatment of anxiety. After 3 months of therapy, the client states that the medication does not seem to be as effective as at the beginning of therapy. What would be the reason for the change in the client's response to lorazepam? • Intravenous lorazepam is distributed quickly to the brain after long-term use. • Lorazepam redistributes out of the brain quickly if used long term. • The half-life of lorazepam in the blood would increase if used long term. • Tolerance to lorazepam can occur if it is used long term.

• Tolerance to lorazepam can occur if it is used long term. Explanation: Tolerance to lorazepam and the other benzodiazepines can occur if they are used long term, requiring larger doses to achieve a therapeutic effect. The long-term use of lorazepam would not have an effect on the way it distributes through the body or its half-life. This client would not be receiving lorazepam intravenously. Question 10

16 of 20 The home care nurse is following a client discharged from the hospital with a prescription for diazepam. On the initial visit what is the nurse's priority related to this medication? • The importance of taking medications for insomnia only occasionally • Warning signs that may indicate serious adverse effects • Ensuring the client knows how to contact the provider if needed • Teaching about herbal therapies that may be a safe and effective alternative

• Warning signs that may indicate serious adverse effects Explanation: The home care nurse should provide thorough client teaching, with a priority teaching point being the warning signs the client may experience that indicate a serious adverse effect. Although this may have been discussed by the discharging nurse in the hospital, this is essential information for the client to thoroughly understand. The client should have received the provider's contact information when leaving the hospital but the home care nurse may need to review this, even though it is not the priority teaching point. It is important to take hypnotics as ordered, and no more than necessary, but education about adverse effects is a priority.

9 of 20 A truck driver has been diagnosed with a generalized anxiety disorder (GAD) and lorazepam has been prescribed. The client asked the nurse how this medication will affect his job. The nurse would advise him how? • avoid driving at night, because lorazepam affects the wake-sleep cycle and can lead to drowsiness. • avoid driving until he is aware of the adverse effects. • drive only 2 hours after consuming the drug and stop when it's time for the subsequent dose. • change his profession, because the drug has long-term effects after cessation of therapy.

• avoid driving until he is aware of the adverse effects. Explanation: Drowsiness, sedation, and ataxia may occur when the drug is started, but these effects should disappear once the client becomes accustomed to the drug. The nurse must advise the client to avoid driving or performing any other tasks that require mental alertness and concentration until the effects of the drug are known. Lorazepam does not have prolonged effects after cessation of therapy, so the nurse would not advise the client to change his profession. The client should avoid driving until the drug effects are known, instead of avoiding driving only at night or for 2 hours after drug consumption.

19 of 20 Which condition will place the client prescribed a benzodiazepine at risk for toxicity? • increased calcium • decreased potassium • decreased albumin • normal bicarbonate

• decreased albumin Explanation: Clients with liver disease are at risk for adverse effects with drugs that are highly bound to plasma proteins. Neither increased calcium nor decreased potassium will have a direct impact on benzodiazepine toxicity. The normal bicarbonate will not contribute to benzodiazepine toxicity.

In addition to relieving agitation and anxiety, what is a rationale for using benzodiazepines in the treatment of a critically ill client? • decreased cardiac workload • increased level of consciousness • increased diffusion and perfusion • decreased blood pH

• decreased cardiac workload Explanation: Antianxiety and sedative-hypnotic drugs are often useful in critically ill clients to relieve stress, anxiety, and agitation. Their calming effects decrease cardiac workload (e.g., heart rate, blood pressure, force of myocardial contraction, myocardial oxygen consumption) and respiratory effort. They do not decrease blood pH, increase diffusion and perfusion, or increase level of consciousness (LOC). Question 20

5 of 5 When providing health education for a client, the nurse should cite what significant risk associated with the adverse effects of benzodiazepines? • persistent insomnia • personality changes • dependence • suicide

• dependence Explanation: Benzodiazepines carry a significant risk for dependence. They do not cause suicidality, personality changes, or insomnia.

20 of 20 An older adult client is diagnosed with generalized anxiety disorder. The use of benzodiazepines in this client population creates a specific need for which intervention? • education regarding sexual dysfunction • seizure precautions • frequent dysrhythmias monitoring • falls risk assessment

• falls risk assessment Explanation: Adverse effects of benzodiazepines may include contributing to falls and other injuries unless clients are carefully monitored and safeguarded. Seizures, dysrhythmias, and sexual dysfunction are not characteristic adverse effects.

A client is taking diazepam (Valium) and asks how the drug works. The nurse knows that the mechanism of action of diazepam is augmentation of: • dopamine (DA) neurotransmission. • gamma-aminobutyric acid (GABA) neurotransmission. • acetylcholine (Ach) neurotransmission. • serotonin (5HT) neurotransmission.

• gamma-aminobutyric acid (GABA) neurotransmission. Explanation: GABA is a major inhibitory neurotransmitter in the central nervous system. Benzodiazepines such as diazepam augment the inhibitory action of GABA, producing a calming, decreased anxiety response. Benzodiazepines do not directly affect 5HT, DA, or ACh neurotransmission. Question 12

19 of 20 The etiology of anxiety involves which physiological process? • stimulation of the parasympathetic nervous system • stimulating effects of somatotropin • adrenocortical suppression • increased activation of the autonomic nervous system

• increased activation of the autonomic nervous system Explanation: Clinical manifestations of anxiety include overactivity of the autonomic nervous system, such as dyspnea, palpitations, tachycardia, sweating, dry mouth, dizziness, nausea, and diarrhea. Somatotropin is not directly involved, and the adrenal cortex is not suppressed during times of anxiety. The parasympathetic nervous system is not stimulated during times of anxiety.

A client who is experiencing acute alcohol withdrawal is being treated with intravenous lorazepam (Ativan). This drug achieves a therapeutic effect by: • inhibiting the action of monoamine oxidase. • affecting the regulation of serotonin and norepinephrine in the brain. • increasing the amount of serotonin available in the synapses. • increasing the effects of the neurotransmitter GABA.

• increasing the effects of the neurotransmitter GABA. Explanation: Like all benzodiazepines, lorazepam increases the effects of GABA, which has an inhibitory effect on the CNS. However, none of the benzodiazepines act like GABA or increase the amount of GABA present. MAOIs inhibit monoamine oxidase and tricyclic antidepressants primarily affect serotonin and norepinephrine levels. SSRIs increase the availability of serotonin in the synapses. Question 9

The nurse is caring for a black resident in a long-term care facility with a history of an anxiety disorder. The client is receiving oral lorazepam (Ativan) 2 mg t.i.d. What assessment should the nurse prioritize? • level of consciousness • mucous membrane integrity • sleep quality • suicidal ideation

• level of consciousness Explanation: Special care should be taken when anxiolytic or hypnotic drugs are given to black clients. About 15% to 20% of black clients 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. Nurses should assess all clients for suicidal ideation, but there is no particular reason why this client's risk would be especially high. The nurse should assess the client's sleep quality, but this does not affect the client's safety level, like decreased level of consciousness. There is no particular reason for assessing the client's mucous membranes. Question 17

2 of 5 A client is using the herbal preparation kava to manage anxiety. The nurse will advise the client that kava may cause: • gastrointestinal damage. • kidney damage. • liver damage. • central nervous system damage.

• liver damage. Explanation: Kava is hepatotoxic. People using kava should be advised to monitor for signs and symptoms of liver failure. Kidney, central nervous system, and gastrointestinal damage have not been reported for kava.

Which of the client's current signs and symptoms should cause the nurse to suspect that the client is experiencing lorazepam withdrawal? • severe insomnia for the past several nights • current mood is described as "depressed" • unstable blood sugars in recent days • uncharacteristic memory lapses

• severe insomnia for the past several nights Explanation: Common signs and symptoms of benzodiazepine, like lorazepam, withdrawal include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Memory lapses, unstable blood sugars, and depression are not typical.

A nurse is planning teaching with a client who has had an anti-anxiety medication prescribed. A priority action for would be to: • try to avoid factors that make you go to sleep. • take the medication 30 minutes prior to going to bed. • try to identify and avoid factors that cause nervousness or insomnia. • take the medication just as you go to bed.

• try to identify and avoid factors that cause nervousness or insomnia. Explanation: The nurse should try to help the client identify and avoid factors that cause nervousness or insomnia, such as caffeine-containing beverages and stimulant drugs. This may prevent or decrease the severity of nervousness or insomnia so sedative-type drugs are not needed. The nurse would not tell the client to take their anti-anxiety medications just prior to going to bed or within 30 minutes of going to bed. The nurse would not teach the client to avoid factors that make the nurse go to sleep. Question 6