Getz1
General Anesthesia
Anesthesia that depresses the CNS with a loss of consciousness
Local Anesthesia
Anesthetic that blocks pain conduction of nerve impulses at the site of administration
Which nursing consideration is most important when caring for a patient receiving epidural anesthesia while in labor? A. pain scale B. blood pressure C. infection control D. level of consciousness
B
A nurse is teaching a patient about zolpidem. Which is most important for the nurse to include in the teaching of this drug? A) the maximum dose is 20 mg/day B) it is used for short-term treatment less than 10 days C) for older adults, the dose is 15 mg at bedtime D) the drug should only be used for 21 days or less
B
A patient who has received an intravenous (IV) dose of midazolam will be switched to oral (PO) formulation. Which adjustment in dosing does the nurse anticipate? A. Lower PO dose B. Higher PO dose C. No adjustment in dose D. This medication cannot be given PO
B
An older adult complains of insomnia. Which suggestion would be most appropriate for the nurse to provide as an initial method to deal with this issue? A) "take Benadryl pills each evening before bedtime" B) "drink warm milk or chamomile tea before bedtime" C) "develop an exercise regimen for the evening hours" D) "take naps during the day whenever you feel drowsy"
B
Cyclobenzaprine exerts an effect within which time span? A. 30 minutes B. 1 hour C. 2 hours D. 6 to 8 hours
B
Inhalable gas can be used as a general anesthetic? A. carbon dioxide B. nitrous oxide C. Carbon monoxide D. nitrogen dioxide
B
hallucinogens: physiological effects
Physiological Nausea/vomiting Chills Pupil dilation Increased BP, pulse Loss of appetite Insomnia Depersonalization decreased respirations
complications of cirrhosis
Portal Hypertension esophageal varices- defective blood floe from liver cause varicose veins in esophagus. hepatic encephalopathy-impairs mental functioning- depression, confusion, coma, death ascites
Hypomania does NOT cause MARKED impairment in social/occupational functioning
What is the main difference between mania and hypomania (besides the duration of symptoms)?
50-125 mg/ml is therapeutic range for bipolar disorder You can take levels 3-4 days after initiation. (lithium is 4-5 days after)
What is the therapeutic range for valproic acid in treating bipolar disorder? How many days after initiation should you draw a level?
Acute mania & maintenance therapy
What is valproic acid indicated for?
Mild = 1.5-2 mEq/L Moderate 2.0-2.5 mEq/L Severe = >2.5 mEq/L any level > 6 or >4 for chronic Lithium use
What levels of lithium in the blood define mild, moderate, and severe toxicity? What lithium toxicity level should you treat the patient with hemodialysis?
Valproic acid and lamotrigine (valproic acid with lamotrigine will decrease lamotrigine clearance)
What two bipolar medications have a drug interaction?
Need to check more frequently because of its autoi-induction Check every 1-2 weeks for the first 2 months then every 3-6 months thereafter Therapeutic range = 4-12 mcg/mL
When do you need to monitor carbamazepine and what do we want our levels to be?
Airway
When general anesthesia is given, the priority is to monitor what?
When is appears Benzodiazepine is causing respiratory distress
When is Flumazenil given?
We should draw levels 4-5 days after initiation, 10-12 hours after that days dose. Acute mania = 0.8-1.2 mEq/L Maintenance therapy = 0.6-1.2 mEq/L Elderly = 0.6-0.8 mEq/L
When should you monitor lithium levels after first starting a patient on it and what are our goal for levels for acute mania, maintenance therapy, and the elderly?
Analeptics
When someone is taking Barbiturates and respiratory depression occurs, what should we give them?
Anatagonist drugs used to treat persons with substance dependence:
block or change the effects of the addictive drug, reducing the desire for it
The ____ theories of alcohol abuse have focused on people's expectations of alcohol's effects and their beliefs about the appropriateness of using it to cope with stress
cogntive
Confusion, excitement, and delirium are observed in the _______________ or _____________ stage
excitement, delirium
Research suggests that midazolam works by stimulation of the ________-_______________ __________ (GABA) or adjacent receptors.
gamma-aminobutyric acid
Complementary and alternative therapy for depression includes __________ __________ and _______ __________ __________. Should discontinue use of herbal products ____ to ____ weeks before surgery. Always check with the health care provider before taking herbal treatments.
ginkgo biloba, St. John's Wort, 1, 2
Morphine, heroin, codeine, and methadone are all
opioids
Phenobarbital
Long acting Barbiturate is what?
REM
(rapid eye movement) describes sleep in which vivid dreams typically occur; this type of sleep increases as the night progresses while stage 4 sleep decreases; consists of body actions: you may dream, flutter eyes, talk, moan, twitch or scratch
Cannabis Use Disorder: Effects on the Body
-Cardiovascular- tachycardia, orthostatic hypotension Tachycardia, increases O2 demand -Respiratory: tar build up in lungs, airway disorders -Reproductive: infertility -CNS: high feeling -Sexual functioning: enhanced sexual experience
client and family education
-Nature of the illness- effects on the body and how it effects their life -triggers/stressors -support services
DSM-5 criteria: substance addiction
-a failure to fulfill obligations at school, work, home -attempts to control or cut down fail -intense craving and time spent looking for the item -problems with interpersonal relationships -recurrent substance related legal issues -withdrawal symptoms occur when use is discontinued
substance intoxication
-development of a reversible syndrome of symptoms followed by excessive use of a substance -direct effect on the CNS -disruption of physical and psychological functioning -judgement is disturbed and social and occupational functioning impaired
role of the nurse in caring for substance abuse disorders
-examine your own beliefs -identify those at high risk mental issues -used evidence based screening tools -provide patient safety -establish knowledge of available services -include the patient in the process -establish a therapeutic non judgmental relationship with the pt.
Most U.S. states consider a person to be under the influence of alcohol if his or her blood-alcohol level is _____ or above.
0.08
A patient with major depression has been prescribed fluoxetine. What nursing diagnosis would be most appropriate? 1. Social Isolation 2. Mobility, Impaired Physical 3. Urinary Elimination, Impaired 4. Sensory Perception, Disturbed
1
Which of the following statements about e-cigarettes is not true?
12% of middle school students report using e-cigarettes
The duration of action of cyclobenzaprine is _____ to _____ hours. Patients may notice improvement in muscle spasm for up to 24 hours. The medication may be taken more frequently (every ____ hours) for consistent pain/spasm.
12, 24, 8
REM and nonREM
2 big phases of the sleep cycle?
Local and General
2 major types of anesthetic
-Benzodiazepines -Barbiturates -Others
3 types of sedative hypnotics?
Benzos should not be used for longer than _________ weeks if used for sedation.
3-4
As of 2018 how many states have legalized cannabis use in some form for medical reasons?
31 states and D.C.
-Decrease Pain -Minimize Cardiovascular Problems -Reduces Post Anesthesia GI Distress -Decreases the Amount of General Anesthesia Given
4 benefits of balanced anesthesia
-Analgesia -Excitement -Surgical Anesthesia -Medullary Depression
4 stages of anesthesia
Approximately _____ deaths occur in the U.S. each year due to smoking-related illness.
480,000
Globally, approximately ______ percent of people over the age of 15 abstain from alcohol?
62%
A nurse is providing discharge teaching to a patient prescribed cyclobenzaprine. Which statement would be appropriate to include in the teaching? A. "Notify your health care provider if you think you might be pregnant." B. "Finish the entire prescription, even if you feel better." C. "You may drive 4 hours after you take the medication." D. "You may take a sleeping pill, if needed, but only if you have 8 hours to sleep."
A
A patient has been prescribed a skeletal muscle relaxant and asks the nurse, "Why was I told not to drive or participate in activities that require mental alertness while taking this drug?" Which response by the nurse is appropriate? A. "Sedation is a common side effect of skeletal muscle relaxants." B. "A decrease in peripheral vision is a side effect of skeletal muscle relaxants." C. "A decrease in muscle tone is a side effect of skeletal muscle relaxants." D. "Short-term memory loss is a side effect of skeletal muscle relaxants."
A
A patient is admitted to the emergency department with an overdose of benzodiazepine. Which antidote will the nurse expect to administer? A) flumazenil B) naloxone C) naltrexone D) nalmefene
A
A patient who has been taking 5 mg of oral cyclobenzaprine PO tid for 6 weeks asks for a renewal of the prescription. Which information is of concern to the nurse? A. Length of time patient has been on medication B. Frequency that the medication is prescribed C. Dose of the medication that is prescribed D. Route that current medication is prescribed
A
For which reason should a patient taking cyclobenzaprine report adverse effects to the health care provider? A. To prevent respiratory depression B. To decrease prescribed dose C. To increase prescribed dose D. To prevent hypertension
A
It is important for the nurse teaching the patient regarding secobarbital to include which information about the drug? A) it is a short-acting drug that may cause one to awaken early in the morning B) it is an intermediate-acting drug that frequently causes rapid eye movement rebound C) it is an intermediate-acting drug that frequently causes a hangover effect D) it is a long-acting drug that is frequently associated with dependence
A
The nurse awakens a patient to administer oral therapies. Which state of sleep will the patient return to after taking the medication? A. stage 1 NREM B. stage 2 REM C. stage 3 NREM D. stage 4 REM
A
The nurse plans to provide patient teaching to Ms. Wilson regarding cyclobenzaprine. Which information would the nurse share with Ms. Wilson? CASE STUDY DETAILS A. Avoid concomitant use with alcohol and other central nervous system (CNS) depressants. B. Take cyclobenzaprine every 8 hours around the clock. C. Take cyclobenzaprine every morning before driving to work to increase range of motion in her cervical spine. D. Take cyclobenzaprine on an empty stomach.
A
The nurse teaches a patient that a muscle relaxant should not be abruptly stopped based on which rationale? A. To avoid rebound spasms B. To prevent heart palpitations C. To decrease chances of depression associated with chronic pain D. To prevent permanent nerve damage
A
The nurse understands that excretion of cyclobenzaprine occurs via which organ system? A. Kidneys B. Liver C. Lungs D. Skin
A
The nurse would monitor which laboratory values for a patient taking cyclobenzaprine? A. Liver function tests B. Creatine kinase C. Serum amylase and lipase D. Arterial blood gases
A
The patient has recently been prescribed a sedative-hypnotic medication and reports experiencing a "hangover"-type effect upon awakening. What does this symptom indicate? A) a need to change to a different medication B) toxicity level of the medication C) allergic reaction to the medication D) Inadequate amount of the medication
A
The patient is undergoing anesthesia in preparation for a procedure. The patient is experiencing hallucinations and dreams. Which anesthesia stage is the patient most likely experiencing? A) stage 1 B) stage 2 C) stage 3 D) stage 4
A
The patient is undergoing anesthesia in preparation for surgery. The patient is starting to have difficulty speaking and is losing the sensation of pain. Which anesthesia stage is the patient most likely experiencing? A) stage 1 B) stage 2 C) stage 3 D) stage 4
A
Which drug is commonly used for moderate (conscious) sedation and is a short-acting benzodiazepine? A) midazolam B) halothane C) isoflurane D) lidocaine
A
Which medication would the nurse instruct an otherwise healthy patient to avoid while taking midazolam? A. Morphine B. Loratadine C. Acetaminophen D. Aspirin
A
Which type of anesthetic will be used during the suturing process of a toddler with a scalp laceration requiring stitches? A. local anesthesia B. spinal anesthesia C. topical anesthesia D. general anesthesia
A
Which type of sleep is a patient experiencing if the patient reports, "I cannot stay sleep. I am up and down all night!"? A. insomnia B. narcolepsy C. rapid eye movement (REM) sleep D. nonrapid eye movement (NREM) sleep
A
implementation: detoxification
A process in which the body adjusts to functioning without alcohol provide a safe and supportive environment, administer substitution therapy
Which common side effects are associated with centrally-acting muscle relaxants? SELECT ALL THAT APPLY. A. Dizziness B. Drowsiness C. Bradycardia D. Hypertension E. Dyspnea F. Polydipsia
A, B
treatment modalities for substance related disorders
AA counseling group therapy support groups, narcotics anonymous, al anon
A patient is to receive conscious sedation for a minor surgical procedure. Which drug administration should the nurse expect? (Select all that apply) A) propofol to reduce anxiety B) lidocaine to provide local anesthesia C) midazolam to promote sedation and following of commands D) ketamine for rapid induction and prolonged duration of action E) phenobarbital for short-acting duration of sleep
A, B, C
Which nursing assessments are important for a patient prescribed cyclobenzaprine? A. Level of consciousness B. Breathing C. Blood pressure D. Blood glucose E. Vision checks
A, B, C
Which products, if taken concurrently with midazolam, could result in drug interactions? SELECT ALL THAT APPLY. A. Kava kava B. Erythromycin C. Zolpidem D. Penicillin E. Fish oil F. Atropine
A, B, C
Which is a state of general anesthesia? A. surgical B. analgesia C. recovery D. excitement E. medullary paralysis
A, B, D, E
Which nursing assessments, if applicable, must be completed before the administration of midazolam? A. Allergy history B. Medication history C. Auscultation of lung sounds D. Blood pressure E. Pregnancy test
A, B, D, E
The nurse will teach the patient that cyclobenzaprine can relieve which symptoms? A. Muscle stiffness B. Muscle paralysis C. Localized muscle spasms D. Pain with range of motion E. Spasticity caused by myasthenia gravis
A, C, D
Which instruction would the nurse provide a patient taking cyclobenzaprine to avoid dizziness and fainting? A. Stand slowly from a sitting position B. Take medication without food C. Check blood glucose levels D. Maintain adequate hydration E. Stop the medication immediately
A, D
The nurse educates a patient to avoid which drugs while taking muscle relaxants? A. Alcohol B. Ibuprofen C. Over-the-counter vitamins D. Kava kava E. Valerian
A, D, E
Which drug is a non-benzodiazepine? A. zaleplon B. sufentanil C. estazolam D. eszopiclone E. zolpidem tartrate
A, D, E
Which of the following primarily contributes to the fact that the relapse rate for people undergoing any kind of treatment for alcohol abuse and dependency is high?
Abstinence violation effect
What causes hepatic encephalopathy?
Accumulation of neurotoxins (ammonia). the liver cant convert ammonia to urea for excretion
effects of alcohol: pancreatitis
Acute -usually occurs 1-2 days after binge drinking -s/s: severe epigastric pain, nausea, vomiting, gastric distention Chronic leads to pancreatic insufficiency resulting in steatorrhea, malnutrition, weight loss and diabetes
Spinal fluid leak
After spinal anesthesia the patient needs to lay flat on their back to decrease the risk of what?
Which of the following is a central nervous system depressant?
Alcohol
Classes of Psychoactive Substances
Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives/hypnotics Stimulants Tobacco
why do people in countries such as France show lower rates of alcohol-related substance disorders than do people in other countries?
Alcohol is usually consumed with meals in France
_____ are stimulants prescribed for the treatment of attention problems, narcolepsy, and chronic fatigue.
Amphetamines
stimulant use disorder
Amphetamines Synthetic stimulants Non-amphetamine stimulants Cocaine Caffeine Nicotine
effects of alcohol: alcoholic myopathy
Alcoholic myopathy: Thought to result from same B vitamin deficiency that contributes to peripheral neuropathy Acute: Sudden onset of muscle pain, swelling, and weakness; reddish tinge to the urine; rapid rise in muscle enzymes in the blood (muscles decompensated) Chronic: Gradual wasting and weakness in skeletal muscles (no pain b/c nerves in bad shape)
Benzodiazepines
Alprazolam, Lorazepam, Temazepam, and Diazepam are examples of what?
Listening to soothing music
Another nonpharmalogical way to help induce sleep is?
Dennis is undergoing treatment to deal with his alcohol use disorder. Whenever he takes this drug, he can't even have one alcoholic drink because he starts to feel sick and dizzy and feels like vomiting. Which drug is he most likely using?
Antabuse
Flumazenil
Antidote for Benzodiazepines is what?
Hangover Effect
Anything that alters REM sleep, can cause a what?
Which of the following is typically reduced due to caffeine intake?
Appetite
Not typically because they could possible cause a switch to hypomania, so only use in conjunction with anti-mania treatments to offset
Are antidepressants used in the treatment of bipolar?
Which statement made by Ms. Wilson regarding cyclobenzaprine indicates further teaching is required by the nurse? CASE STUDY DETAILS A. "I should avoid taking the cyclobenzaprine and ibuprofen together." B. "I can take this medication as long as I want." C. "I should take this medication with food." D. "I need to taper this medication if I want to stop taking it."
B
Which side effects of muscle relaxants would the nurse educate a patient about? A. Coughing B. Headache C. Nausea D. Tinnitus E. Amber urine F. Muscle weakness
B, C, F
Because they prolong GABA
Barbiturates depress neuronal activity more than Benzodiazepines because?
Block Sodium Channels
Barbiturates do what at high doses?
____ is the tendency to be impulsive, sensation-seeking, and prone to antisocial behaviors such as violating laws.
Behavioral under-control
Discuss the different cognitive-behavioral intervention methods for treating substance-related disorders
Behavioral: based on aversive classical conditioning; covert sensitization therapy; contingency management programs Cognitive: Help clients identify situations in which they are most likely to drink and lose control over their drinking, as well as their expectations that alcohol will help them cope in those situations (motivational interviewing, relapse prevention, AA)
A patient received spinal anesthesia. Which is most important for the nurse to monitor? A) loss of consciousness B) hangover effects and dependence C) hypotension and headaches D) excitement or delirium
C
Pedro is at a party and has taken a substance that has made him euphoric and disinhibited; he then experiences lethargy, loss of coordination and other signs of central nervous system depression. He has most likely taken:
Benzodiazepines
Which of the following are legally manufactured and sold by prescription, ususally as sedatives for the treatment of anxiety and insomnia
Benzodiazepines
-Suppress Stage 4 of nonREM sleep -Delay REM Sleep
Benzodiazepines do what 2 things regarding sleep?
Distinguish binge drinking from heavy drinking
Binge drinking involves the consumption of five or more drinks within a couple of hours for men and four or more drinks within a couple of hours for women. Heavy drinking refers to binge drinking on five or more days in a month
Men = Women Suggests a BIOLOGICAL cause
Bipolar prevalence: Men (=, > or < ) Women This is true across all cultures.... what does this suggest?
What term refers to alcohol-induced amnesia for the events that occurred while one was intoxicated
Blackout
___________________ is not a side effect of centrally-acting muscle relaxants. Medications that may cause this include beta blockers (metoprolol) and cardiac glycosides (digoxin).
Bradycardia
Other sedative hypnotics
Busiprone, Chloral Hydrate, Zaleplon, and Zolpidem are examples what?
Which barbiturate is classified as intermediate-acting?
Butabarbital
A patient is complaining of gastrointestinal symptoms when taking a prescribed muscle relaxant. The nurse would recommend which beverage to help alleviate these symptoms? A. Water B. Lemonade C. Milk D. Tea
C
A patient taking lorazepam asks the nurse how this drug works. The nurse should respond by stating that it is a benzodiazepine that acts by which mechanism? A) depressing the central nervous system, leading to a loss of consciousness B) depressing the central nervous system, including the motor and sensory activities C) increasing the action of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) to GABA receptors D) creating an epidural block by placement of the local anesthetic into the epidural space
C
During which phase of sleep do most recallable dreams occur? A) stage 1 of nonrapid eye movement sleep (NREM) B) stage 2 of nonrapid eye movement sleep (NREM) C) during rapid eye movement (REM) sleep D) throughout all phases of sleep
C
The most serious adverse effect of spinal anesthesia is: A) hypotension B) headache C) respiratory distress D) tachycardia
C
The nurse is assessing a patient with a history of chronic sedative use. The nurse notes the patient is exhibiting muscle twitching, tremors, and dizziness, especially on moving from sitting to standing. Which reaction is the patient experiencing? A) tolerance to the sedative B) underdosing of the sedative C) dependence to the sedative D) an allergic response to the sedative
C
The nurse is caring for a patient who is taking barbiturate. Which assessment finding requires immediate action by the nurse? A) history of a sleep disorder B) +1 pitting edema of the lower extremities C) urinary output of 10 mL/h D) blood pressure of 140/95 mm Hg
C
The patient has recently been prescribed a benzodiazepine and reports experiencing vivid dreams. What does this symptom indicate? A) overdosage of the medication B) allergic reaction to the medication C) therapeutic effect of the medication D) inadequate amount of the medication
C
The patient is receiving anesthesia in preparation for surgery. The patient will be in which stage of anesthesia when the procedure occurs? A) stage 1 B) stage 2 C) stage 3 D) stage 4
C
The patient is receiving triazolam as part of treatment for insomnia. The patient complains of experiencing memory problems. The nurse recognizes this as: A) evidence of an allergic response B) an idiosyncratic effect C) an adverse reaction to the drug D) evidence of drug toxicity
C
Which method would the nurse use to administer cyclobenzaprine to facilitate the greatest amount of absorption? A. Administer with grapefruit juice B. Administer with a full meal C. Administer on an empty stomach D. Administer intravenously
C
Which nursing consideration is most important for a patient receiving intravenous fentanyl? A. restlessness B. hypertension C. respiratory depression D. level of consciousness
C
Which symptoms characterize medullary paralysis associated with anesthesia? A. shallow and increased respiration B. auditory and visual hallucinations C. respiratory and circulatory collapse D. confusion, excitement, and delirium
C
which reversal agent needs to be on hand when administering intervenous lorazepam? A. naloxone B. zolpidem C. flumazenil D. phytonadione
C
Stimulant use effects on body
CNS effects Cardiovascular effects- increased demand for oxygen Pulmonary effects Gastrointestinal and renal effects Sexual functioning
Inhalant Use Disorder-Effects on the Body
CNS effects- neuropathy, speech problems, tremors Respiratory effects: coughing, wheezing, dyspnea, emphysema, pneumonia. Increased airway resistance due to inflammation of the passages. Gastrointestinal effects: abdominal pain, N/V, rash around nose and mouth Renal system effects: acute or chronic renal failure
opioid use disorder effects on the body
CNS effects: depression Gastrointestinal effects: constipation Cardiovascular effects: hypotension Sexual functioning: inhibits sexual function
which lab values are elevated due to alcoholic myopathy?
CPK, LDH, AST
Yes
Can Benzodiazepines cause a hangover effect?
Postdural Puncture Headache
Can occur if someone doesn't drink a lot of fluids after a spinal procedure?
Carbamazepine is a pregnancy category D. backup birth control recommended
Carbamazepine is a pregnancy category _____. Is backup birth control recommended?
Discuss how cocaine is able to provide a feeling of reward and pleasure?
Cocaine activates those areas of the brain that register reward and pleasure. Cocaine blocks the reuptake of dopamine into the transmitting neuron, causing it to accumulate in the synapse. the rapid, strong effects of cocaine on the brain's reward centers makes this substance more likely than most to lead to a stimulant use disorder
______________________ is the most commonly used centrally acting skeletal muscle relaxant and is often prescribed to reduce spasms caused by musculoskeletal injuries. It is not effective against muscle spasms caused by _____________ disorders.
Cyclobenzaprine, CNS
A patient is taking a hypnotic nightly to enhance sleep. The patient experiences vivid dreams and nightmares. This may be associated with: A) hangover B) tolerance C) hypersensitivity D) REM rebound
D
A patient is taking triazolam. Which instructions about this drug are important for the nurse to include? A) it may be used as a barbiturate for only 4 weeks B) use as a nonbenzodiazepine to reduce anxiety C) it may cause agranulocytosis and thrombocytopenia D) avoid alcohol and smoking while taking this drug
D
The nurse administered midazolam intravenously. Which assessment, if noted by the nurse, would require immediate intervention? A. Confusion B. Nausea C. Blurred vision D. Cough
D
The nurse would withhold the prescribed midazolam for the patient reporting which condition? A. Peripheral vascular disease B. Muscle spasms C. Acute low back pain D. Hepatitis B
D
Use of muscle relaxants is contraindicated in patients with which condition? A. Brain tumor B. Diabetes C. Acromegaly D. Hepatic disease
D
What would indicate to the nurse that a patient taking a sedative-hypnotic requires more teaching? A) the patient wants to listen to music on the radio B) the patient has saved her urine to be measured C) the patient says she has taken 1800 mL of fluid today D) the patient requests a cup of kava kava tea to help her get to sleep faster
D
Which assessment finding would require the nurse to hold the prescribed midazolam? A. Heart rate 110 beats/minute B. Respiratory rate 26/minute C. Oxygen saturation 93% D. Blood pressure 90/60 mm Hg
D
Which classification of barbiturates is useful for maintaining long periods of sleep? A. temporary B. short acting C. long-acting D. intermediate acting
D
Which nonpharmacologic nursing invention can be provided to help promote sleep in a patient who reports unusual sleep patterns and lack of sleep? A. Increase fluid intake before bedtime B. sleep more during the day C. have an alcoholic drink before bedtime D. arise at a specific hour in the morning
D
Which nursing intervention would be most appropriate for a patient taking temazepam? A) monitor for fever B) give drug intravenously only C) monitor daily weights D) tell patient to ask for help before standing
D
Which of the following makes cocaine more likely than most substances to lead to a stimulant use disorder? A. It's easily availability B. The absence of short-term health problems C. Symptoms of fatigue and insomnia upon withdrawal D. Its rapid, strong effects on the brain's reward centers
D. Its rapid, strong effects on the brain's reward centers
Which of the following is a reason why the strong age difference in alcohol use disorders decline with age? A. With age, the liver metabolizes alcohol at a faster rate B. The increasing percentage of body water decreases the absorption of alcohol C. Older people are financially more secure than younger ones D. People who have used alcohol excessively may die before they reach old age
D. People who have used alcohol excessively may die before they reach old age
-Sedative Hypnotics -Opioid/nonopioid analgesics -Anticonvulsants -Antipsychotics
Depressants include what 4 drug types?
Single dose half life = 25-60 hours Chronic dosing half life = 12-17 hours It is different because carbamazepine can auto-induce its own metabolism
Describe carbamazepine's half life with a single dose compared to its half life with chronic dosing. Why is it different?
Hank began snorting cocaine about three years ago. He said that the first high was the astounding, exciting, mind-blowing experience he'd ever had. However, he has never been able to recapture that inital euphoria, and now he needs more and more of cocaine to get anywhere near his first experience. Hank has most likely:
Developed a tolerance to cocaine
substance withdrawal
Development of symptoms that occurs upon abrupt reduction or discontinuation of a substance that has been used Symptoms are specific to the substance that has been used Disruption in physical and psychological functioning, with disturbances in thinking, feeling, and behavior
Inhalant Use Disorder: Intoxication
Develops during or shortly after use of or exposure to volatile inhalants Symptoms include: Dizziness, ataxia, muscle weakness Euphoria, excitation, disinhibition, slurred speech Nystagmus, blurred or double vision Psychomotor retardation, hypoactive reflexes Stupor or coma *Not many withdrawal symptoms
Substance abuse
Diagnosis given when recurrent substance use leads to significant harmful consequences
Substance dependence
Diagnosis given when substance use leads to physiological dependence or significant impairment or distress
3 examples of CNS depressants used for moderate sedation include:
Diazepam, Lorazepam, Midazolam
Baclofen, dantrolene, and tizanidine are all examples of centrally acting muscle relaxants used to treat spasticity. ___________________, a ___________________, has also been successfully used to treat muscle spasticity.
Diazepam, benzodiazepine
NonREM
Does REM or nonREM occur first?
Type 1 does not always have depressive episodes Type 2 always has depressive episodes
Does type 1 bipolar always have depressive episodes? What about type 2?
Depressant
Drug that decreases or lowers bodies basic function and neuro-activity
Hypnotic Effect
Higher doses of sedatives have what kinda affect?
Alcohol use disorder: phase 2
Early alcoholic phase: begins with blackouts—brief periods of amnesia that occur during or immediately following a period of drinking; alcohol is now required by the person. *alcohol stops being a relief *preoccupation with drinking *fear or guilt about drinking
effects of alcohol: alcoholic cardiomyopathy
Effect of alcohol on the heart is an accumulation of lipids in the myocardial cells, resulting in enlargement and a weakened condition. -S/S- CHF, arrhythmia, tachycardia, dyspnea, SOB, exercise intolerance - Tx: permanent abstinence from alcohol, oxygen, digitalization, decreased sodium intake and diuretics
sedative hypnotic effects on the body
Effects on sleep and dreaming Respiratory depression Cardiovascular effects- decrease in BP with large doses Renal function Hepatic effects- jaundice Body temperature- high doses decrease body temp Sexual functioning- increase in libido followed by inability to keep erection
substance withdrawal
Experience of clinicially distress in social, occupational, or other areas of functioning due to the cessation or reduction of substance use. Symptoms vary greatly across substances
_______________ is the antidote for benzodiazepine overdoses. Naloxone, naltrexone, and _______________ are used in opioid or narcotic overdose.
Flumazenil nalmefene
Tyramine
Foods rich with ___________ are a nonpharmalogical method to make someone drowsy and promote the release of Melatonin?
long acting
For sleep, patients want to take _________ acting benzos and barbs?
increase dose by 15-20% for extended release
For valproic acid, if you switch from delayed to extended release you must (increase/decrease) dose by ___%.
What is a central nervous system depressant approved for the treatment of the sleep disorder narcolepsy
GHB
_____________ ______________ products increase oral absorption and systemic availability of midazolam.
Grapefruit juice
moderate
Half life for Benzodiazepines is what?
Long
Half life of barbiturates is what?
Short
Half life that Melatonin Agonists have?
CAGE questionnaire
Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?
hallucinogens: psychological effects
Heightened response to color, sounds Distorted vision Sense of slowed time Magnified feelings Paranoia, panic Euphoria, peace Depersonalization Derealization Increased libido
loser doses, slower titration, and lower serum goals (0.6-0.8)
How do you change dosing of lithium in elderly?
20 hours not metabolized by liver, renally excreted as urine
How long is lithium's half life? how is it metabolized?
Mania = Biopolar I Hypomania = Bipolar II
If a patient has mania, they have which bipolar? Which bipolar if they have hypomania?
Medications
If nonpharmalogical methods do not work in assisting someone in inducing sleep, then what may be required for the patient to take?
Respiratory Distress or Failure
If regional/spinal anesthesia is injected too high then what can happen?
You can still give them lithium, there's no need to take them off of it Start levothyroixne or some other thyroid rx
If someone has has hypothyroidism, how does this affect your choice to give them lithium?
Hypnosis
Induction of sleep
GABA
Inhibitory neurotransmitter inhibits the actions of neurons leading to a decrease in neuron excitability in the brain
Butabarbital
Intermediate acting Barbiturate is what?
Which of the following observations is true of the drug phencyclidine (PCP)
It has many of the same effects as hallucinogens
chemically impaired nurse
It is estimated that 10 to 15 percent of nurses suffer from the disease of chemical dependency. Alcohol is the most widely abused drug, followed closely by narcotics.
Which of the following is true of freebase cocaine?
It is usually smoked in a water pipe or mixed in a tobacco or marijuana cigarette
__________________ is an herb that may interact with CNS depressants.
Kava kava
Which of the following is a rapid-acting anesthetic that produces hallucinogenic effects ranging from rapture to paranoia to boredom? A. Valium B. Ketamine C. Methadone D. Rohypnol
Ketamine
Ones with a Long Half Life
Kind of Benzos that should be avoided in older adults are what?
Sympatholytic/parasympathomimetic
Kind of affect that depressants have on the ANS?
Category C - avoid in less than 16
Lamotrigine is a pregnancy category ___. It is recommended to avoid use in people less than ____ due to the benign rash
Which of the following is true of amphetamine use?
Like cocaine, amphetamines can produce perceptual illusions.
2 to 3 times the normal population (neonatal toxicity may occur - hypotonia, bradycardia, CV abnormalities, cyanosis, seizures/shock) reduce dose before delivery contraindicated: breast feeding
Lithium increases risks of birth defect by ______ times. How does this affect the dose at delivery? When is lithium contraindicated?
Lithium is a pregnancy category D. It should be avoided in the first trimester because it can cause Epstein's Anomaly, a congenital heart defect that causes tricuspid regurgitation. increases risk of birth defect by 2-3 times
Lithium is a pregnancy category _____. It should be avoided in the first trimester because it can cause ________, a congenital heart defect that causes tricuspid regurgitation. It increases risk of birth defects by __ times.
alcohol withdrawal
Long-acting benzodiazepines occurs within 4-12 hours after heavy use. may progress to delirium on the second or third day symptoms: tremors of hands, tongue, eyelids, N/V, malaise or weakness, tachycardia, sweating, elevated blood pressure, depressed mood, transient hallucinations, headache, insomnia
predisposing factors: personality factors
Low self-esteem Frequent depression Passivity antisocial behavior Inability to communicate effectively
What are the symptoms of phencyclidine (PCP) intoxication?
Lower doses: a sense of intoxication, euphoria or affective dulling, talkativeness, lack of concern, slowed reation time, vertigo, eye twitching, mild hypertension, abnormal involuntary movements, and weakness Intermediate doses: disorganized thinking, distortions of body image, depersonalization, and feelings of unreality. A use may become hostile, belligerent, and even violent Higher doses: amnesia and coma, analgesia sufficient to allow surgery, seizures, severe respiratory problems, hypothermia, and hyperthermia
Which of the following is a conclusion about alcohol abuse offered by social learning theories?
Maladaptive patterns of alcohol use may be passed down through a family through modeling
Which gender is more likely to use inhalants?
Males
Sedative Hypnotic Drugs
Medications that promote sleep by suppressing the CNS but can also be used to sedate someone, reduce anxiety, and cause hypnosis
Retrograde Amnesia
Melatonin can cause what?
Which of the following best explains why those who take heroin while on methadone do not experience heroin's intense psychological effects?
Methadone blocks receptors for heroin
Balanced Anesthesia
Method of using general anesthesia that involves a multi drug regimen
________________ undergoes first-pass metabolism when administered orally, with only 40% to 50% of the medication reaching circulation.
Midazolam
__________________ lowers blood pressure, which can lead to orthostatic hypotension, dizziness, falls, and safety risks. The nurse should not administer __________________ to an already hypotensive patient to avoid adverse reactions. (ONE ANSWER FOR BOTH BLANKS)
Midazolam
Mixed episodes are associated with bipolar I. This means they meet criteria for manic episodes and 3 symptoms of major depressive episode in the same day every day for at least 1 week
Mixed episodes are associated with ______. This means they meet criteria for manic episodes and 3 symptoms of _______ in the same day every day for at least 1 week
Which of the following was widely used as a pain reliever in the ninteeth century, until it was found to be highly addictive?
Morphine
effects of alcohol: Wernicke's encephalopathy
Most serious form of thiamine deficiency in alcoholic patients - usually comes with Karsakoff's psychosis - paralyzed ocular muscles, double vision, oversleep, stupor Tx: thiamin- oral or IV
____ has proven useful in treating alcohol dependents and abusers, possibly because it blocks the effects of endorphins during drinking
Naltrexone
Nearly all of those who experience mania will go on to develop major depressive disorder
Nearly all of those who experience mania will go on to develop __________
lithium
Neonatal toxicity may occur with ______ use, causing cyanosis, hypotonia, bradycardia, CV changes, seizures/shock. It is recommended that you REDUCE dose prior to delivery
Which of the following is an alkaloid found in tobacco?
Nicotine
Which class of inhalants dilates blood vessels and relaxes muscles and are sometimes used as sex enhancers
Nitrites
Zolpidem (Ambien)
Nonbenzodiazepines like ________________ can help combat insomnia
The primary ingredient in ________ sleep aids is an ________________ such as diphenhydramine.
OTC, antihistamine
Opioid Use Disorder
Opioids of natural origin (opium, morphine, codeine) Opioid derivatives( heroin, hydromorphone, oxycodone, carfentanil) Synthetic opiate-like drugs (Meperidine, methadone, fentanyl)
Benzodiazepines
Out of Benzos or Barbs which.are safer for older adults?
What is synesthesia?
Overflow from one sensory modality to another
People with bipolar II disorder meet the criteria for a hypomanic episode AND a major depressive episode. They NEVER meet the criteria for manic episodes.
People with bipolar II disorder meet the criteria for a __________ episode AND a _________ episode. They NEVER meet the criteria for _________ episodes.
20 x more likely to attempt suicide than general population and ~10% are successful with suicide
People with bipolar are ___ times more likely to attempt suicide than general public and suicide completion rates approach ___%
NonREM
Phases 1-4 of sleep cycle and does not include REM
Name two barbiturates classified as long-acting?
Phenobarbital, methobarbital
Alcohol use disorder: phase 1
Prealcoholic phase: Characterized by use of alcohol to relieve everyday stress and tensions of life *you have some tolerance
When using hallucinogens, people say they hear colors and see sounds. They feel at one with their surroundings, and time seems to pass very slowly. Which term was coined to describe these experiences?
Psychedelic
At which stage of sleep cycle do individuals experience most of the recalled dreams?
REM
What are the most common SE and adverse reactions of sedative-hypnotics? Hangover, __________ rebound, __________, __________, excessive __________, __________ depression, hypersensitivity
REM, dependence, tolerance, depression, respiratory
The benzodiazepine medications are known to delay _________ sleep and thus generate _________ dreams.
REM, vivid
Which barbiturate is classified as short-acting?
Secobarbital
Barbiturates
Sedative hypnotic that has an ultra action availability
Benzodiazepines
Sedative hypnotic that increases the action of GABA to inhibit the actions of the cells leading to a decrease in neuron excitability in the brain
What is the common pharmacologic options for insomnia?
Sedative-hypnotics
Psychomotor
Sedatives diminish _________ function but do not affect a person LOC
Secobarbital
Short acting barbiturate is used to sedate patients for procedures
More than once a day
Short acting sedative hypnotics need to be taken how many times each day to get a therapeutic effect
Key findings of psychological theories on substance use disorders
Social learning theories: children and adolescents may learn substance-use behaviors by modeling the behavior of their parents and important people in their culture Cognitive theories: focuses on people's expectations of alcohol's effects and their beliefs about the appropriateness of using it to cope with stress. people who expect alcohol to reduce their stress and who do not have more adaptive means of coping are more likely than others to drink alcohol when they are upset and to have social problems related to drinking One personality characteristic consistently related to an increased risk of substance use disorders is behavioral under-control
REM Sleep
Someone will be drowsy and fatigued if they do not get what?
Regional or Spinal
Spinal block, epidural block, caudal block, and saddle block are examples of what?
Nerve Blocks
Spinal block, epidural block, caudal block, and saddle block can be referred to as what?
If the sleep cycle is interrupted at stage IV non-rapid eye movement sleep, which stage begins the sleep cycle again?
Stage 1
Stage 1: Analgesia
Stage of anesthesia involves analgesia without amnesia
Stage 2: Excitement
Stage of anesthesia that could have nausea, vomiting, hyperactivity, or irregular respiration
Stage 4: Medullary Depression
Stage of anesthesia that involves the depression of vasomotor and respiratory centers leading to coma and death; we never want patients to get to this point
Stage 3: Surgical Anesthesia
Stage of anesthesia that occurs when the patient is asleep with normal respiration and BP and when the surgery/procedure is being performed
Stage 2: Light Sleep
Stage of nonREM sleep when some regular noises may not wake a person up
Stage 1: Somnolence
Stage of nonREM sleep when you feel sleepy but are easily aroused
Stage 3 and 4: Slow and Deep Sleep
Stage of nonREM sleep, it's harder to arouse the deeper they go into sleep
Symptoms only need to be present for 4 days for hypomania
Symptoms only need to be present for ______ for hypomania
True; they have a "class effect" in helping manic symptoms
T/F: Atypical/2nd generation antipsychotics can be used as monotherapy or combination therapy for acute mania in bipolar disorder
False, both can be used to treat mania
T/F: Only mood stabilizers can be used to treat mania, atypical antipsychotics cannot
T/F most stimulant abusers begin using appetite suppressants
TRUE
Which of the following observations about tabacco use is true?
Tabacco use is increasing in developing countries over the past few decades
Which of the following statements about opioid use and abuse in the U.S. is true?
The abuse of opioids in the U.S. has become a national epidemic
With repeated use of substances such as cocaine, heroin, and amphetamines, more of the drug is needed to produce the desired effects. Which of the following helps explain this statement.
The brain reduces its production of dopamine
Alcohol use disorder: phase 4
The chronic phase: characterized by emotional and physical disintegration. The person is usually intoxicated more often than sober. *depression, SI *withdrawal- can be fatal for heavy drinkers *life threatening physical manifestations *helplessness
Alcohol use disorder: phase 3
The crucial phase: person has lost control; physiological dependence is clearly evident (drinking is their main focus) *binge drinking *sickness, loss of consciousness *dirty and unkept *sometimes lost job and relationship
What is one reason identified in the text that explains the significant increase and severity of the opioid epidemic in the U.S.
The increase and severity of the opioid epidemic is partially attributable to increased used of illegally-made synthetic opiods like fentanyl
What is one of the four categories of harmful consequences that suggest substance abuse?
The individual fails to fulfill important obligations at work, home, or school as a result of substance use
What was the outcome of Project MATH that compared the different interventions designed to help people with alcohol dependency: Cognitive-behavioral intervention, motivational interviewing and enhancement, and a 12-step program based on Alcoholics Anonymous (AA) model?
The three interventions were equally effective in reducing drinking behavior and preventing relapse over the following year
Stage 5 paradoxical sleep
The type of sleep encountered during REM when internally, the brain and body are active; while externally, the body appears calm and inactive
Why are alcohol and narcotics contraindicated with barbiturates and benzos?
They may further depressed the CNS (respirations)
Melatonin Agonist
This other OTC sedative hypnotic regulates circadian rhythm, does not decrease REM sleep and is taken about an hour before bed
Benzodiazepines are used to reduce alcohol dependence. Why is the dosage of the specific benzo decreased each day while using it to treat a substance use disorder?
To ensure that the person does not become dependent on the benzo
To get a diagnosis for Bipolar I, you must have at least 1 manic episode
To get a diagnosis for Bipolar I, you must have at least (#) manic episode(s)
What is the first stage of alcohol withdrawal?
Tremulousness, weakness, and profuse perspiration
Antidepressant Groups --______________ antidepressants (TCAs) --Selective ______________ ______________ inhibitors (SSRIs) --Serotonin ______________ ______________ inhibitors (SNRIs) --______________ antidepressants --______________ ______________ inhibitors (MAOIs)
Tricyclic, Serotonin reuptake, norepinephrine reuptake, atypical, monoamine oxidase
Valproic acid is a pregnancy category D. It has a teratogenic BBW because it can cause facial defects, spina bifida, and neural tube defects
Valproic acid is a pregnancy category ____ if being used for bipolar disorder (X for migraines). It has a teratogenic black box warning because it can cause what 3 things?
Respiratory Depression
We must monitor for what when giving depressants?
Benzo or barbs
We should not give what to patients that already have a low respiratory rate and are difficult to arouse?
1. Diuretics - avoid thiazides 2. NSAIDS - avoid NSAID use > 3 consecutive days and use ASA or sulindac 3. Ace inhibitors - avoid combo
What 3 classes of drugs can increase lithium concentration and how do you combat this?
Pretty tolerable, but might get a benign rash (14%)
What adverse effects does lamotrigine have?
Dizziness, diplopia, ataxia, increase in liver enzymes, pancreatitis, hepatitis, and hyponatremia Hyponatremia has the biggest incidence rate
What are some adverse effects of carbamazepine? Which has the biggest incidence rate?
DIG FAST Distractibility Irresponsibility/impulsivity Grandiosity Flight of ideas Activity increased/agitation Sleep decreased Talkativeness Need 3 or more
What are some symptoms of mania? How many do you need for a diagnosis?
Tremor Cognitive problems N/V/D Dermatologic (rash) Weight gain Polyuria (excessive urination)
What are the adverse effects for lithium?
1. Thrombocytopenia and neutropenia 2. alopecia (patchy baldness) 3. Weight gain (more than lithium) BBW for pancreatitis and hepatic failure
What are the adverse effects of valproic acid?
PTh BEER Pregnancy, checking before starting Thyroid (TSH level), checking for hypothyroidism Blood (CBC), checking for thrombocytosis or leukocytosis ECG, checking for bradycardia Electrolytes, checking for Na/K Renal, checking for Na/K, Cr/BUN
What are the baseline things to check prior to administering lithium? What are you checking for with each?
Mood stabilizers: lithium and lamotrigine Atypical antipsychotics: quetiapine, lurasidone (esp. in kids), and olanzapine MS and AAP also first line for mania (except not lamotrigine or lurasidone because they dont treat mania)
What are the typical first-line treatment mood stabilizers and atypical antipsychotics used to treat depressive episodes?
It is used for acute manic and mixed episodes It is not a first-line medication and is not usually used as monotherapy
What is carbamazepine used for? Is it a first-line drug and is it used as monotherapy?
It can cause Stevens-Johnson syndrome (SJS) (also called toxic epidermal necrolysis (TEN)) so they recommend genetic testing for HLA-B 1502 in people of asian descent because of their increased risk for these fatal rashes It can also cause aplastic anemia and agranulocytosis
What is carbamazepine's black box warning?
Basically bipolar II symptoms lasting for at least 2 years, but they never reach the criteria for mania, hypomania, or MDD. Symptomatic periods must be present for at least 50% of the time and they cannot be asymptomatic for more than 2 consecutive months. For children this is only for 1 year
What is cyclothymic disorder? Symptomatic periods must be present for at least _____% of the time and they cannot be asymptomatic for more than (#) consecutive months. How is it different in children?
You need to titrate slowly to begin due to BBW (SJS/TEN), patient must take every day to avoid restarting titration
What is important to know about lamotrigine dosing?
Maintenance therapy & bipolar depression It has been known to double the time between depressive episodes compared to a placebo
What is lamotrigine used for? Why is especially good for bipolar depressive therapy?
increase serotonin (5HT) and GABA function and decrease dopamine function gold std for bipolar disorder
What is the MOA for lithium? What is it the gold standard treatment for?
It can cause serious rash such as Stevens-Johnson syndrome (SJS) (otherwise known as toxic epidermal necrolysis (TEN)) - carbamazapine also causes this There's an increased chance for these when used as adjunctive therapy
What is the black box warning for lamotrigine? How is it different in mono vs adjunct therapy?
Can cause hepatic failure and pancreatitis 1. It's contraindicated for mitochondrial & urea cycle disorders 2. It can cause hyperammonemic encephalopathy (diseased brain due to increased ammonia) 3. There's an increased risk when used with topiramate
What is the blackbox warning for valproic acid? Although not a black box warning, what other 3 things do you need to be wary about?
Initial treatment - mood stabilizer or AAP (2nd gen) Combo of above: When the patient is so severely ill that they need hospitalization or if they have psychotic symptoms
What is the initial treatment for BPD? When should you use combination therapy for bipolar disorder?
Atypical are preferred because the have less adverse effects and extrapyramidal symptoms
Which are preferred and why between atypical and typical antipsychotics when treating mania?
Lithium
Which biopolar medication is good for its anti-suicidal effects?
Lamotrigine Lurasidone
Which bipolar medication is specifically not effective for mania? Which atypical antipsychotic is not effective for mania?
Bipolar disorder
Which disorder consists of episodic mood shifts into mania, major depression, hypomania, and a mixed mood state?
- antidepressants (TCA, MAOI, SSRI) - anxiolytics (buspirone, benzodiazapines) - stimulants (methylphenidate, cocaine, amphetamines) - endocrine (corticosteroids, thyroid supplements, androgens) - miscellanneous - levodopa, alcohol, etc. Corticosteroids seems to provoke mania more so than the others
Which medications can cause a switch into mania? Which one provokes a manic episode more than the others?
avoid antidepressants in severe recent manic states and rapid cycling (esp TCAs due to higher switch rates) could use antidepressants only in conjunction with anti-manic meds
You should avoid _______ use in severe, recent manic states and in rapid cycling. When could you use them? (especially avoid _______ due to higher switch rates)
Nonbenzodiazepines
Zolpidem and Eszopiclone are examples of what?
Lithium is the gold standard for treatment for bipolar maintenance therapy
_______ is the gold standard treatment for bipolar maintenance therapy
Rapid cycling is when a person with bipolar experiences at least 4 manic, hypomanic, or depressive episodes within 1 year. They are seen more in women. Anti-depressants might trigger this
_______ is when a person with bipolar experiences at least 4 manic, hypomanic, or depressive episodes within 1 year. They are seen more in (women/men). What is one thing that might trigger this?
Mania is associated with mood disturbance and increased activity. Symptoms must be present for at least 1 week for at least most of the day or require hospitalization
________ is associated with mood disturbance and increased activity. Symptoms must be present for at least _______ for at least most of the day or require hospitalization
Codependency
a condition in which a family member or friend sacrifices his or her own needs to meet the needs of an addict
deficit - depression excess - mania
a deficit in NE, DA, and serotonin leads to _____. An excess of NE and DA leads to _____.
Many medications used for muscle spasms are known to have a sedative effect and should not be taken in addition to CNS depressants such as ______________, prescription ______________, or ______________.
alcohol, narcotics, barbiturates
Drug Holiday
a person gradually starts taking less of a medication for a couple days and then takes a couple days off from the medication to let the body realize there's no levels of the drug and then starting taking the drug again to make lower doses of the drug more effective
According to the philosophy of AA, the only way to control alcohol intake is to
abstain completely
treating codependence: re-identification stage
accept the label of codependent and take responsibility for their own dysfunctional behavior
pattern of addiction: sedative/hypnotics
addiction can begin after a doctor prescribed a drug for insomnia or anxiety or young people who use substances illegally obtained for recreational use
effects of alcohol: gastritis
alcohol breaks down he mucosal barrier and then HCL erodes the stomach lining s/s- inflammation, epigastric distress, nausea, vomiting, gastric distention
_______________ : --sedative-hypnotic: benzodiazepine (CSS IV) ..............CONTRAINDICATED... • respiratory depression • acute alcohol intoxication • psychotic reaction • recent respiratory depressants • hypersensitivity • __________ adults • sleep _______________ • renal or liver dysfunction • depression • _______________ ideation • drug abuse ..............PHARMACODYNAMICS • PO onset = 15-30 mins • Peak: IR, 1-2 h ER, 9 h • Duration UK --Therapeutic Effects/use • treatment of anxiety and panic disorders -----Mechanism of Action: • CNS depression • binds receptors to _______________ system and reticular formation • increases GABA to GABA receptors • shift of chloride ions leads to less excited ability and stabilize neuronal membranes ..............SIDE EFFECTS • lethargy • drowsiness • dizziness • headache • constipation • anterograde amnesia • memory impairment • fatigue • agitation • ataxia • increased appetite • blurred vision • decreased and increased libido • dry mouth • nausea • edema • weight gain/loss ..............ADVERSE REACTIONS • depression • tolerance • dependence • withdrawal • hypotension • seizures • tachycardia ..............LIFE THREATENING: • __________ failure • Stevens-Johnson syndrome
alprazolam, older, apnea, suicidal, limbic, hepatic
Side effects of midazolam include: retrograde _____________, _____________, confusion, headache, slurred _____________, paresthesia, _____________, weakness, hypotension, _____________, blurred vision, nystagmus, diplopia, loss of balance, nausea, vomiting, increased _____________, urticaria, pain, pruritus at injection site, rash, _____________, and dyspnea.
amnesia, euphoria, speech, tremors, tachycardia, increased salivation, coughing
stimulant use disorder: withdrawal
amphetamine & cocaine: may result in dysphoria, fatigue, sleep disturbances, and increased appetite caffeine withdrawal: headache, fatigue, drowsy, irritable, muscle paint and stiffness, N&V Nicotine withdrawal: dysphoria, anxiety, difficulty concentrating, irritability, restlessness, increase in appetite
stimulant use disorders: intoxication
amphetamine & cocaine: produce euphoria, impaired judgement, confusion, changes in vitals, come or death caffeine intoxication: usually occurs following consumption in excess of 250mg- most common s/s- restless and insomnia
Auditory and visual hallucinations are observed during the induction of ______________ phase.
analgesia
Stages of general anesthesia include: stage 1 or __________ stage stage 2 or __________/delirium stage stage 3 or __________ stage stage 4 or medullary __________ stage
analgesia, excitement, surgical, paralysis
assessment of substance abuse disorders
assessment tools drug history and assessment use of the clinical withdrawal assessment of alcohol scale Michigan alcohol screening test (MAST) CAGE questionnaire
Adverse effects of midazolam are _____________ ___________, apnea, _____________, laryngospasm, and respiratory _____________.
cardiac arrest, bronchospasms, depression
Cyclobenzaprine use is contraindicated in: patients with _______________________ disorders, hyperthyroidism, _________________ impairment, narrow-angle glaucoma, or myasthenia gravis. Also patients taking _________________, and children and in individuals with _________________ _________________ injuries, cerebral palsy, or paralytic ileus.
cardiovascular, hepatic, MAOIs, spinal cord
effects of alcohol: alcoholic hepatitis
caused by excessive use of alcohol s/s- enlarged tender liver, N/V, lethargy, anorexia, elevated WBC's, fever, jaundice *ascites and weight loss in sever cases
predisposing factors: biochemical
changes in brain structure and neurochemistry with addiction
predisposing factors: biological factors
children of alcoholics more likely to develop alcoholism
effects of alcohol: cirrhosis of the liver
cirrhosis is the end stage of alcoholic liver disease caused by HEAVY alcohol use widespread destruction of liver cells that are replaced by fibrous or scar tissue *similar symptoms to hepatitis
Jim is over at a friend's house to pregame before going out. He takes a substance that provides an instant rush of euphoria followed by heightened self-esteem, alertness, energy, and feelings of competence. He begins taking the substance regularly and develops symptoms such as grandiosity, hypersexuality, and impulsive behavior. He has most likely taken:
cocaine
Midazolam (Versed) is commonly administered for _____________ sedation for ____________ surgery or procedures.
conscious, minor
predisposing factors: cultural and ethnic influences
consumption based on culture
_____ provide reinforcements for individuals to curtail their use of substances, for example, employment, housing, or vouchers for purchases at local stores.
contingency management programs
Assessment before administering __________________ nurse should obtain patient's health history to identify the cause of the muscle __________________; cyclobenzaprine is only effective for muscle spasms of local __________________. Obtain __________________ function studies and a complete blood count (CBC).
cyclobenzaprine, spasms, origin, liver
Carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, and orphenadrine citrate are all examples of centrally acting muscle relaxants. Many of these medications, with the exception of _________________________, may also lead to drug dependence. _______________ and drowsiness are common side effects of these medications.
cyclobenzaprine, vertigo
Strong age differences in alcohol use disorders
decline as people age
All the following are withdrawal symptoms associated with opiods, EXCEPT:
delirium tremens
Alcohol
depressant
Before administering any CNS __________________ perform a medical history including a thorough drug history and identification of any __________________. Determine for current use of any drugs and herbal supplements to help avoid any possible drug __________________. Obtain base line vital signs, particularly the blood pressure in both __________________ and __________________ positions.
depressant, allergies, interactions, sitting, supine
Alcohol is considered a _____ because it ______
depressant; slows the central nervous system
The philosophy of Alcohol Anonymous (AA) is based on the _____ model of alcoholism
disease
fetal alcohol spectrum disorder
disorder affecting babies whose mothers consumed large amounts of alcohol while they were pregnant physical, mental, behavioral, learning disabilities with lifelong implications
meds for alcoholism
disulfiram (antabus) Naltrexone (reViva) Nalmefene (revex) SSRI Acamprotsate (campral)
Some drugs, like cocaine and amphetamines produce a strong sense of reward or a "high" by increasing the availability of the neurotransmitter _____.
dopamine
Amphetamines release the neurotransmitters _____ and block their reuptake
dopamine and norepinephrine
sedative hypnotic use disorder
drugs of diverse chemical structures that are all capable of inducing varying degrees of CNS depression barbituates nonbarbituate hypnotics antianxiety agents club drugs (rophynol)
The compound 3,4-methylenedioxymethamphetamine is also known as:
ecstasy
predisposing factors: sociocultural factors
effects of modeling and imitation
implementation: rehabilitation
encourage continues participation in long term treatment promote participation in outpatient support system (90 meetings in 90 days AA) assist client to identify alternate sources of satisfaction provide support for health promotion and maintenance
Before medications are used, various nonpharmacologic methods should be used to promote sleep, including avoiding ______________ before bedtime and avoiding ______________ during the day.
exercise, naps
substance intoxication
experience of significant maladaptive behavioral and psychological symptoms due to the effect of a substance on the central nervous system
treating codependence: core issues stage
face the facts that relationships cant be managed by force of will. each partner must be independent and autonomous
Most muscle relaxants are usually taken for no longer than a _______ weeks. Once the muscle spasms diminish, the medication should be ___________ and discontinued.
few, tapered
Binge drinking is defined as consuming:
five or more drinks within a couple of hours for men
What causes ascites in alcoholism?
fluid from the liver is under increased pressure so the stomach fills with fluid
the effects of alcohol are influenced by
food in the stomach, stress, fatigue
Opioid Use: withdrawal
for short acting drugs (heroin)- symptoms occur within 6-8 hours, peak 1-3 days and gradually subside in 5-10 days for long acting drugs (methadone)- symptoms usually occur within 1-3 days, peak between 4-6 days, and subside in 14-21 days For ultra short acting (meperidine)- symptoms peak in 8-12 hours and subside in 4-5 days
Why do you think gambling disorder is included in the chapter of substance-related and addictive disorders?
gambling disorder represents a behavioral addiction. it is persistent despite social, financial, and psychological consequences. it seems to share many risk factors and clinical patterns with the substance use disorders
Contraindications for Midazolam include acute narrow-angle _______________, concurrent use of a potent CYP3A4 inhibitor. Caution use with _______________/_______________/_______________ impairment, impaired gag reflex, heart failure, treated open-angle glaucoma, _______________, concurrent use of CNS depressants, alcohol dependency, and older adult and debilitated patients.
glaucoma, renal, hepatic, pulmonary, obesity
The _____ are a mixed group of substances, including lysergic acid diethylamide (LSD) and peyote
hallucinogens
Cannabis Withdrawal
happens about 1 week after heavy use and cessation s/s include irritable, anger or aggression, anxiety, sleep disturbances, decreased appetite, depressed mood, stomach pain, tremors, sweating, fever, chills, headache
Psychologist Alan Marlatt and colleagues have argued that a more credible approach to college drinking than abstinence programs is to recognize drinking as normative behavior and focus education on the immediate risks of drinking to excess and the payoffs of moderation. This is an example of a:
harm reduction model
Low-grade hypertension, combined with increases in the levels of triglycerides and low-density lipoprotein, puts alcohol abusers mostly at increased risk for:
heart disease
Physical and/or psychological dependence is the result of chronic __________ use. Physical dependence results in the appearance of specific __________ symptoms when a drug is discontinued after __________ use. The severity of withdrawal symptoms depends on the drug and dosage.
hypnotic, withdrawal, prolonged
hypothyroidism - depression sx hyperthyroidism - mania, anxiety sx
hypothyroidism is more associated with _____ symptoms, hyperthyroidism is more associated with _____ symptoms
cannabis intoxication
impaired motor coordination; euphoria; anxiety; sensation of slowed time; impaired judgment physical symptoms: red eyes, increased appetite, dry mouth, tachycardia, impaired motor skills
effects of alcohol: leukopenia
impaired production of WBC's
chemically impaired nurse behaviors
increase in wasting drugs, higher incidence of incorrect counts, higher record of signing out drugs for other nurses poor concentration, difficulty meeting deadlines, inappropriate responses, poor memory, problems with relationships, irritability, tendency to isolate, elaborate excuses for behavior, unkept appearance, patient complaints of inadequate pain control, discrepancies in documentation high absenteeism if persons source is outside of work person may rarely miss work if the substance source is at work
How does grapefruit affect alprazolam?
increases alprazolam levels
inhalant use disorder
induced by inhaling the aromatic hydrocarbons found in substances such as fuels, solvents, adhesives, aerosols, propellants, and paint thinners huffing
effects of alcohol: esophagitis
inflammation and pain in the esophagus occurs because of the toxic effects of alcohol on the esophageal mucosa *also caused by frequent vomiting
GABA is an _____________ neurotransmitter in the brain and _____________ CNS stimulation; thus it can produce sedation, relax skeletal muscles, and induce sleep, anesthesia, and amnesia.
inhibitory, blocks
Although all drugs used to treat ____________ have the potential to be ____________, addictive, or habit-forming, the class with the lowest likelihood for these problems is the ____________ receptor agonists. This is the ____________ reason why they are the first-line drugs to treat insomnia.
insomnia, abused, benzodiazepine, main
• The ______________-acting barbiturates, such as butabarbital, are useful as sleep ______________ for maintaining long periods of sleep. Because these drugs take approximately 1 hour for the onset of sleep, they are not prescribed for those who have trouble getting to sleep. ______________ ______________ should be closely monitored in persons who take these ______________.
intermediate, sustainers, Vital signs, barbiturates
Alcohol intoxication
intoxication occurs between 100-200 mg/dl (blood levels) death reported between 400-700mg/dl mood lability , aggressive impulses, impaired judgement, impaired functioning, nystagmus
sedative hypnotics use disorder: intoxication and withdrawal
intoxication- disinhibition and aggressiveness to coma and death with increasing doses of the drug withdrawal- onset of symptoms depends on half life can be life threatening. hand tremors, hallucinations, N/V
predisposing factors: cognitive factors
irrational thinking patterns blame things on others additive thinking- they rationalize why they do something
The ____________-acting group includes phenobarbital, which is used to control ______________ in epilepsy.
long, seizures
id a nurse is chemically dependent does their license get taken away?
it might get suspended or revoked or they may avoid disciplinary action if they agree to seek treatment
Which of the following observations is true of cocaine?
its effects wear off quickly
The intravenous anesthetic agent that is contraindicated for the patient with a history of psychiatric disorders is _______________ _______________.
ketamine hydrochloride
treating codependence: survival stage
let go of denial that the problem exists
Muscle relaxants are metabolized in the ______________; therefore a patient with ______________ disease would not take these medications. A decrease in the ______________ of these medications may lead to toxicity in patients with ______________ disease.
liver, hepatic, metabolism, hepatic
Topical
local anesthetic that decreases the sensitivity of nerve endings and is used on the mucous membranes, skin, and on burns; examples are a Lidocaine patch/gel or Benzocaine
Regional or Spinal
local anesthetic that is injected into the subarachnoid space below the first lumbar space
Intermediate-acting barbiturates are useful for maintaining ___________ periods of sleep. Short-acting barbiturates are used for procedure ___________. The long-acting group is used for control of ___________.
long, sedation, seizures
predisposing factors: conditioning
many substances create a pleasurable experience that encourages the user to repeat it. learned behavior
cannabis use disorder
marijuana hashish oils
Gradual withdrawal from heroin can be achieved with
methadone
This drug is commonly used for preoperative sedation, procedural sedation, and severe agitation.
midazolam
Liver dysfunction is a contraindication to ____________________ use. The nurse would withhold the medication and assess _____________ function before administering the medication, because _____________ may impair liver function.
midazolam, liver, hepatitis
Assessment before administering __________________ nurse should determine any contraindications before administering the drug. Assess the __________________ status of the patient. Determine whether the patient has a history of blood dyscrasias or __________________ disease. Determine whether the patient is __________________ or __________________.
midazolam, mental, hepatic, pregnant, breastfeeding
Sedatives
mildest form of CNS depressants
What is the difference between sedation and hypnotic effect? The ____________ form of CNS depression is sedation, which diminishes physical and mental ____________ at lower dosages of certain CNS depressants but does not affect ____________. Increasing the drug ____________ can produce a ____________ affect... Not ____________ but a form of ____________ sleep.
mildest, responses, consciousness, dose, hypnotic, hypnosis, natural
meds for stimulant intoxication and withdrawal
minor/major tranquilizers anticonvulsants antidepressants
meds for opioid intoxication/withdrawal
naloxone naltrexone nalmefene methadone (substitute for opioids) buprenorphine (substitute) Sublocade- monthly injection for mod/sev opioid addiction Clonodine
a substance is defines as any:
natural or synthesized product that has psychoactive effects
Muscle relaxants are believed to depress _______________ action in the spinal cord or _______________ and may even augment neuronal _______________ in the skeletal muscles.
neuronal, brain, inhibition
Pathological gamblers have a greater disruption in the systems regulating the _____________
neurotransmitter dopamine
Discuss the physiological effects on nicotine
nicotine operates on both the central and the peripheral nervous systems. it helps release several biochemicals in the brain. the physiological effects resemble the fight-or-flight responses. Nicotine addicts need nicotine to feel normal because of its effects on the body and the brain.
is damage to the liver with cirrhosis reversible?
no
Can alcoholic myopathy be cured?
no but s/s treated
patient TEACHING for benzodiazepines: --Use ____________ methods to induce sleep -- avoid ____________ and antidepressant, ____________, and opioid drugs while taking benzodiazepines. Respiration ____________ can occur when these drugs are combined. --certain ____________ and alternative therapy products may interact --do not ____________ a motor vehicle or operate machinery while using --check with your healthcare provider about OTC ____________ aids.
nonpharmacological, alcohol, antipsychotic, depression, complementary, drive, sleeping
Hallucinogen intoxication
occur shortly after using the drug s/s: perceptual alteration, depersonalization, derealization, tachycardia, palpitations
During opioid intoxication, a person may experience periods of light sleep with vivid dreams. A person in this state is referred to as being:
on the nod
Which of the following is a popular prescription opiod pain reliever?
oxycodone
effects of alcohol: peripheral neuropathy
peripheral nerve damage pain, burning, tingling, prickly sensations of the extremities, muscle wasting *reversible with absence of alcohol
meds for depressant intoxication and withdrawal
phenobarbitol long acting benzos- help with withdrawal s/s
effects of alcohol: thrombocytopenia
platelet production is impaired due to toxic effects of alcohol *bleeding risk
implementation: intermediate care
provide an explanation of physical symptoms promote understanding and identify causes of addiction provide education and assistance to client and family find their triggers
Which of the following contains antioxidants that can increase "good" cholesterol, along with other chemicals that can help prevent damage to blood vessels and reduce "bad" cholesterol, producing postive cardiac effects
red wine
Hangover Effect
residual drowsiness from intermediate-acting hypnotics; patient may wake up the next day and still be tired
Patients with ____________ disorders should avoid ____________ because they could cause an increase in respiratory ____________.
respiratory, hypnotics, depression
effects of alcohol on the body
reversible CNS depression 20% of a single dose of alcohol is absorbed directly and immediately into the bloodstream through the stomach wall relaxation, loss of inhibition
what does each part of SBIRT mean
screening- assesses severity of substance use and identified the appropriate level of treatment brief intervention: increasing insight and awareness regarding substance use and the motivation behind behavioral change referral to treatment: provides those identified as needing more extensive treatment with access to specialty care
Barbituates
sedative hypnotic prolongs GABA and glycine and depresses neuronal activity even further than Benzodiazepines
Some of the _____________-_____________ drugs can produce a ______________-type effect; if this occurs, the patient should be changed to a different drug.
sedative-hypnotic, hangover
Broad classifications of CNS depressants include ______________________, general anesthetics, ______________________, opioids and nonopioid analgesics, ______________________, antipsychotics, and antidepressants.
sedative-hypnotics, analgesics, anticonvulsants
Family studies show that the relatives of people with substance-related disorders are _____ more likely to have a substance disorder than are the relatives of people with no such disorder
significantly more
Caution should be used with cyclobenzaprine in individuals with ________________ disorders, glaucoma, prostatic hypertrophy, urinary _______________, or hepatic disease and with patients who _______________, drive or operate machinery, concurrently ingest _______________ or other CNS depressants, are older adults, or have regular sunlight or ultraviolet (UV) light _______________.
seizure, retention, breastfeed, alcohol, exposure
treating codependence: reintegration stage
self acceptance and willingness to change relinquish power over others and reclaim their own personal power
why do people act codependent?
sense of control feel responsible for fixing others problems seek approval from others sense of self worth feel responsible for the happiness of others commonly denies a problem exists
The euphoric effects of ectasy and some of the brain damage are considered to be due to alterations in the functioning of _____ in the brain.
serotonin
effects of alcohol: sexual dysfunction
short term: enhanced libido and failure of erection long term: gynecomastia, sterility, impotence, and decreases libido, testicular atrophy women- changes in menstruation, decrease likelihood of pregnancy
Hypnotic drug therapy should usually be __________ term to prevent drug __________ and __________.
short, dependence, tolerance
The __________-to-intermediate-acting benzodiazepines—such as estazolam, temazepam, and triazolam—are considered to be __________ than ____________. __________-acting hypnotic benzodiazepines such as flurazepam, quazepam, and diazepam should be __________.
short, safer, barbiturates, Long, avoided
• The ______________-acting barbiturate secobarbital may be used for procedure ______________. ______________ ______________ should be closely monitored in persons who take these _____________.
short, sedation, vital signs, barbiturates
J.Z. should avoid benzodiazepine drugs because of her age and the drugs' side effects. In older adults, metabolism of drugs is _______________; thus, accumulative effects are likely to occur. _______________ (residual drowsiness) is common with barbiturates and benzodiazepines. Withdrawal symptoms might occur if these drugs were ________________ abruptly.
slower, hangover, discontinued
The purpose of providing inhalation anesthetics during the third stage of general anesthesia is to provide ____________ _____________ of anesthesia. Inhalation may improve oxygenation; however the intent is to help the patient ____________ and induce anesthesia.
smooth induction, relax
The disease model of alcoholism followed by Alcoholics Anonymous (AA) predicts that because of biological, psychological, and spiritual deficits,
some people will lose all control over their drinking once they have one drink
Muscle relaxants are medications used to relieve muscular ___________ and the pain associated with them.
spasms
Increased stimulation from the cerebral neurons cause hyper-excitable neurons, which leads to increased muscle tone and ________________. Central-acting muscle relaxants ________________ the neuron activity in the spinal cord or brain, or enhance the neuronal ________________ on the skeletal muscles.
spasticity, depress, inhibition
intoxication
substance abuse disorders physical and mental state of exhilaration and emotional frenzy or lethargy and stupor
Franco has fallen ill and lost his job, and his wife left him due to his problem with heroin. His friends and family are telling him that he is an addict most likely because he is exhibiting
substance dependence
The DSM-5 authors have combined substance abuse and dependence into one diagnosis called:
substance use disorder
addiction
substance use disorder a compulsive or chronic requirement. the need is so strong as to generate distress if left unfulfilled
a set of physiological and behavioral symptoms that result when people who have been using substances heavily for prolonged periods of time stop or greatly reduce their use
substance withdrawal
meds for hallucinogens/cannabis intoxication/withdrawal
substitution therapy not required unless they have panic or anxiety then use benzos or antipsychotics
Shallow and increased respiration occurs in the ____________ phase.
surgical
Opioid Use: intoxication
symptoms are consistent with the half life of most opioid drugs and usually last for several hours initial euphoria, followed by apathy, dysphoria, psychomotor agitation or retardation, impaired judgement severe opioid intoxication can lead to respiratory depression, coma or death.
Symptoms of alcohol withdrawal
symptoms manifest in three stages: 1. usually begins within a few hours includes trembling, weakness, and profuse sweating 2. Includes convulsive seizures, which may begin as soon as 12 hours after drinking stops but more often appear during the second or third day 3. Charaterized by delirium temens. Fatal in 10% of cases
effects of alcohol: Korsakoff's psychosis
syndrome of confusion- often seen with wernickes encephalopathy loss of recent memories, confabulation (creating events to fill in memory gaps)
what to do if you suspect a coworker is impaired or diverting substances?
tell manager, supervisor, nys health department, SPAN program, nys professional assistance program (PAP)
Circadian Rhythm
the biological clock; regular bodily rhythms that occur on a 24-hour cycle; helps the body stay awake during the day and sleep at night
Dual diagnosis
the client with both substance abuse and another psychiatric illness may be assigned a special program that targets both problems- supportive, prevent relapse, help with coping skills
Medullary paralysis is the __________ stage of anesthesia that is characterized by respiratory and circulatory collapse.
toxic
Muscle spasms may be attributed to _________________ injuries or chronic __________________ diseases (e.g., multiple sclerosis [MS] cerebrovascular accident [CVA], cerebral palsy, or head or spinal cord injuries).
traumatic, debilitating
Symptoms of dependence may include muscular twitching and __________, dizziness, orthostatic hypotension, __________, hallucinations, delirium, and __________.
tremors, delusions, seizures
Memory issues may occur as an adverse reaction to _______________.
triazolam
predisposing factors: psychological
turn to drugs to help medicate a different anxiety you may feel. help increase feelings of power and self worth
hallucinogen use disorders
usually episodic ketamine LSD PCP
Do hypnotics cause tolerance?
yes
Do CNS stimulants have the potential of being abused?
yes! because of their pleasurable effects
_______________ _______________: --sedative-hypnotic: nonbenzodiazepine (CSS IV) ..............CONTRAINDICATED... • hypersensitivity to benzodiazepine • respiratory depression • lactation • renal or liver dysfunction • mental depression • suicidal ideation • pregnancy • children • older adults and debilitated individuals ..............PHARMACODYNAMICS • PO onset = 30 mins • Peak: 90 min • Duration 6-8 hr --Therapeutic Effects/use • treatment of ____________ -----Mechanism of Action: • CNS depression • neurotransmitter _____________ ..............SIDE EFFECTS • drowsiness • lethargy • headache • dizziness • hot flashes • hangover... residual sedation • irritability • ataxia • visual impairment • anxiety • nausea and vomiting • edema • erectile dysfunction • anterograde amnesia • memory impairment • nightmares • binge eating ..............ADVERSE REACTIONS • psychological or physical dependence • tolerance • withdrawal • sleep-related behaviors • hypotension • angioedema • dysrhythmias • depression • suicidal ideation ..............LIFE THREATENING: • _____________ edema • _______________ failure
zolpidem tartrate, insomnia, inhibition, pulmonary, renal
