Ch 14 Drugs for Anxiety

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1

The patient tells the nurse he worries about everything all day, feels confused, restless, and just can’t stop worrying. What is the best response by the nurse?

1. “You have generalized anxiety; I will teach you some relaxation techniques.”

2. “This sounds like social anxiety. You need to calm down and you’ll be fine.”

3. “You have posttraumatic stress disorder (PTSD), and it is time for your therapy session.”

4. “This is called panic disorder; I’ll get your medication for you.”

Rationale 1: Generalized anxiety disorder is characterized by excessive anxiety, but not to panic levels. Other symptoms include restlessness, muscle tension, and loss of focus and ability to concentrate. Relaxation techniques are effective in reducing anxiety. Panic disorder is characterized by intense feelings of apprehension, terror, and impending doom, and increased autonomic nervous system anxiety; the patient does not have these symptoms. Posttraumatic stress disorder is situational anxiety that develops in response to re-experiencing a previous traumatic life event; there is no information that the patient has experienced a trauma. Social anxiety disorder is characterized by “performance anxiety,” i.e., extreme fear when a patient is in a social situation; there is no information to support that this is what the patient is experiencing. Also, telling the patient to “calm down” is non-therapeutic.

2

The nurse has completed group education for patients with anxiety disorders. The education is evaluated as successful when the patients make which statements?Standard Text: Select all that apply.
1. “Relaxation techniques will often decrease anxiety.”
2. “Antianxiety medicine should be used until our anxiety is gone.”
3. “Antianxiety medicine should not be used indefinitely.”
4. “We need therapy to learn where this anxiety comes from.”
5. “We need different medicines for anxiety, and for difficulty in sleeping.”

Correct Answer: 1,3,4
Patients with anxiety disorders should be encouraged to uncover the cause of the anxiety through cognitive-behavioral therapy or other counseling techniques. Nonpharmacological techniques such as relaxation techniques are effective in reducing some levels of anxiety. For most patients, anti-anxiety medication is intended for short-term use. Absence of anxiety is an unrealistic goal because all individuals will have some level of anxiety during their lifetime. Often, the same medication can be used for anxiety as well as insomnia.

3

The patient tells the nurse that she is interested in the human brain, and questions which parts of the brain control anxiety and insomnia. What is the best reply by the nurse?

1. “The limbic system and reticular activating system control anxiety and insomnia.”
2. “The frontal lobes and limbic system control anxiety and insomnia.”
3. “The thalamus and reticular activating system control anxiety and insomnia.”
4. “The limbic system and hypothalamus control anxiety and insomnia.”

Rationale 1: Neural systems associated with anxiety and restlessness includes the limbic system and the reticular activating system. The reticular activating system is responsible for sleeping and wakefulness and performs an alerting function for the entire cerebral cortex. The limbic system and the reticular activating system, not the hypothalamus, are responsible for anxiety and sleep. The limbic system and the reticular activating system, not the frontal lobes, are responsible for anxiety and sleep. The limbic system and the reticular activating system, not the thalamus, are responsible for anxiety and sleep.

4

The patient tells the nurse, “I am really confused after talking to my doctor. He said I would be taking different kinds of medications for my anxiety and insomnia. Will you please explain it?” What is the best response by the nurse?
Standard Text: Select all that apply.

1. “You will be taking medications known as sedative-hypnotics.”
2. “You will be taking medications known as antidepressants.”
3. “You will be taking a medication known as paraldehyde.”
4. “You will be taking medications known as barbiturates.”
5. “You will be taking medications known as benzodiazepines.”

Correct Answer: 1,2,5

The three categories of medications used to treat anxiety and sleep disorders include the benzodiazepines, antidepressants, and sedative-hypnotics. Barbiturates are no longer used for anxiety or insomnia because of significant side effects and the availability of more effective medications. Paraldehyde is no longer used for anxiety or insomnia because of significant side effects and the availability of more effective medications.

5

The patient has generalized anxiety disorder. He asks the nurse, “Will I need medication for this? My neighbor is very nervous and he takes medication.” What is the best response by the nurse?

1. “Medications are a way of life for patients with anxiety disorders.”
2. “Medication is necessary initially; later we will try therapy.”
3. “Probably not, but you shouldn’t compare yourself to your neighbor.”
4. “Medication is necessary when anxiety interferes with your quality of life.”

Rationale 4: It is more productive to identify and treat the cause of anxiety than to use medications. When anxiety becomes severe enough to significantly interfere with the patient’s quality of life, pharmacotherapy is indicated. Medications are not considered “a way of life” for patients with anxiety disorders; many patients can manage anxiety without medications. The nurse does not have enough information to tell the patient that medications will probably not be necessary. Medication combined with therapy is considered the best approach for treatment of anxiety disorders.

6

The patient has been treated by the same physician for 2 years and has had insomnia the entire time. Many different medications have been tried with limited success. What should be the nurse’s primary assessment at this time?

1. Assess for a primary sleep disorder such as sleep apnea.
2. Assess if the patient has been selling his medications to addicts.
3. Assess if the patient has an addictive personality disorder.
4. Assess the patient for a primary personality disorder.

Rationale 1: If the patient has a primary sleep disorder such as sleep apnea, this must be treated to relieve the insomnia. Also, medications such as benzodiazepines depress respiratory drive and would aggravate the sleep apnea. There is no information that the patient might have a personality disorder. If he did, the nurse would most likely recognize this after 2 years of treatment. While it is remotely possible that the patient is selling his medication; it is not likely for a patient with an anxiety disorder to do this. There is no information that the patient might have an addictive personality disorder. If he did, the nurse would know this after 2 years of treatment

7

The patient is scheduled to have an EEG to confirm the presence of a sleep disorder. The patient asks the nurse to describe Stage IV NREM sleep. What is the best response by the nurse?

1. “This is the lightest stage of sleep, and is profoundly affected by anxiety.”
2. “Dreaming occurs here; without dreams you will be irritable and paranoid.”
3. “This is the deepest stage of sleep; without it you will be tired and depressed.”
4. “This stage comprises the greatest amount of sleep time, and is important.”

Rationale 3: Stage IV NREM sleep is the deepest stage of sleep. Patients who are deprived of it experience depression and a feeling of apathy and fatigue. Dreaming occurs in REM sleep, not NREM sleep. Stage IV NREM sleep is the deepest stage of sleep, not the lightest stage of sleep. Stage II NREM sleep, not Stage IV NREM sleep, comprises the greatest amount of total sleep time.

8

The patient has been taking lorazepam (Ativan) for 2 years. The patient stopped this medication after a neighbor said the drug manufacturer’s plant was contaminated with rat droppings. What best describes the nurse’s assessment of the patient when seen 3 days after stopping his medication?

1. Increased heart rate, fever, and muscle cramps
2. Nothing different; it is safe to abruptly stop lorazepam (Ativan)
3. Pinpoint pupils, constipation, and urinary retention
4. A sense of calmness and lack of anxiety

Rationale 1: Many central nervous system (CNS) depressants can cause physical and psychological dependence. The withdrawal syndrome for some central nervous system (CNS) depressants can include fever, seizures, increased pulse, anorexia, muscle cramps, disorientation, etc. It is not safe to abruptly stop lorazepam (Ativan); withdrawal symptoms will occur. Pinpoint pupils, constipation, and urinary retention are signs of opioid use. The patient would be anxious, not calm, during benzodiazepine withdrawal.

9

The patient comes to the emergency department after an overdose of lorazepam (Ativan). The nurse will plan to administer which medication?

1. Pralidoxime (Protopam)
2. Naloxone (Narcan)
3. Flumazenil (Romazicon)
4. Nalmefene (Revex)

Rationale 3: Should an overdose of benzodiazepines occur, flumazenil (Romazicon) is a specific benzodiazepine receptor antagonist that can be administered to reverse central nervous system (CNS) depression. Naloxone (Narcan) is indicated for treatment of opiate overdose. Nalmefene (Revex) is indicated for treatment of opiate overdose. Pralidoxime (Protopam) is indicated for treatment of organophosphate poisoning.

10

The nurse works with a physician who frequently prescribes benzodiazepines. The use of benzodiazepines in which patient would cause the nurse the most concern?

1. An 87-year-old patient who uses a cane for ambulation
2. A 9-year-old child with panic attacks
3. A 42-year-old businessman who travels internationally
4. A 32-year-old mother of two preschool children

Rationale 1: Benzodiazepines should be used with caution in elderly patients. Elderly patients are at highest risk because their metabolism and excretion is slowed; and there is a higher potential for overdose and sedation. There have been few studies of benzodiazepine use in the pediatric population; benzodiazepines must be used with caution, but these patients are not at as high risk as the elderly population. There is minimal concern with benzodiazepine use in a 32-year-old patient. There is minimal concern with benzodiazepine use in a 42-year-old patient.

11

The nurse has completed medication education for the anxious patient who is receiving buspirone (BuSpar). The nurse determines that the patient needs additional instruction when the patient makes which statement?

1. “Side effects I might experience include dizziness, headache, and drowsiness.”
2. “I can take this medication when I feel anxious and it will relax me.”
3. “I have to take this medicine on a regular basis for it to help me.”
4. “I don’t need to worry about becoming dependent on this medication.”

Rationale 2: Buspirone (BuSpar) works by altering levels of neurotransmitters and takes a few weeks to achieve optimal anxiety reduction. It cannot be used as an “as needed” (prn) medication. Side effects of buspirone (BuSpar) include dizziness, headache, and drowsiness. Dependence and withdrawal are less of a concern with buspirone (BuSpar) than with some other antianxiety drugs. Buspirone (BuSpar) works by altering levels of neurotransmitters and takes a few weeks to achieve optimal anxiety reduction. The drug must be taken consistently for this to occur.

12

The patient is receiving zolpidem (Ambien) for treatment of short-term insomnia. What is the primary safety concern of the nurse when the patient takes this medication?

1. Dizziness and daytime sedation
2. Nausea and diarrhea
3. Nausea and gastrointestinal (GI) distress
4. Sleepwalking

Rationale 4: During sleepwalking, a patient may leave the home and cause injury to self. Nausea and gastrointestinal (GI) distress are common side effects of zolpidem (Ambien), and usually subside after a few days on the medication. Dizziness and daytime sedation are common side effects of zolpidem (Ambien), and usually subside after a few days on the medication. Nausea and diarrhea are common side effects of zolpidem (Ambien), and usually subside after a few days on the medication.

13

The patient is receiving escitalopram (Lexapro) for treatment of generalized anxiety disorder. The patient asks the nurse, “I am just nervous, not depressed. Why am I taking an antidepressant medicine?” What is the best response by the nurse?

1. “The same brain chemicals are involved with anxiety as well as depression, and these medications are very safe.”
2. “You are really depressed; it is just manifested as anxiety. These medications are safer than benzodiazepines.”
3. “Your doctor thinks that this is the best treatment for your anxiety, and these medications are safer than benzodiazepines.”
4. “The two disorders go together, and if you treat depression, the anxiety goes away.”

Rationale 1: Antidepressants are frequently used to treat symptoms of anxiety. They reduce anxiety by altering levels of norepinephrine and serotonin. These neurotransmitters are also involved in depression. Selective serotonin reuptake inhibitors (SSRIs) are safer than benzodiazepines, but depression and anxiety are two separate disorders. The patient is being treated for generalized anxiety, this is different from depression. Telling the patient that the doctor knows best is a condescending reply, and does not answer the patient’s question.

14

The patient has been receiving escitalopram (Lexapro) for treatment of obsessive-compulsive disorder. Unknown to the nurse, the patient has also been self-medicating with St. John’s wort. The patient comes to the office with symptoms of hyperthermia and diaphoresis. Which statement best describes the result of the nurse’s assessment?

1. The patient is experiencing symptoms of St. John’s wort toxicity, as the medication was most likely outdated.
2. The patient has contracted a viral infection. Escitalopram (Lexapro) and St. John’s wort are safe to take together.
3. The patient has not been taking escitalopram (Lexapro) and is experiencing withdrawal.
4. The patient has combined two antidepressant medications and is experiencing serotonin syndrome.

Rationale 4: Use caution with herbal supplements such as St. John’s wort, which may increase the effects of escitalopram (Lexapro) and cause serotonin syndrome. The patient’s symptoms are consistent with serotonin syndrome, and there is no evidence that the patient has not been taking the escitalopram (Lexapro). The patient’s symptoms are consistent with serotonin syndrome, and there is no evidence that the patient’s St. John’s wort is outdated. The patient’s symptoms are consistent with serotonin syndrome. It is not considered safe to combine escitalopram (Lexapro) and St. John’s wort.

15

The patient is receiving clonazepam (Klonopin) for the treatment of panic attacks. What is an important medication outcome for this patient as it relates to safety?

1. The patient will verbalize the signs of developing Stevens-Johnson rash.
2. The patient will verbalize the importance of diet restrictions related to this drug.
3. The patient will verbalize the importance of having routine blood work done.
4. The patient will verbalize the consequences of stopping the drug abruptly.

Rationale 4: Abrupt discontinuation of clonazepam (Klonopin) can result in serious withdrawal symptoms. There aren’t any diet restrictions with the use of clonazepam (Klonopin). Routine blood work is not required with the use of clonazepam (Klonopin). Stevens-Johnson rash is not a side effect of clonazepam (Klonopin).

16

An individual who has difficulty sleeping due to two final examinations scheduled for the same day later in the week most likely would be suffering from

1. situational anxiety.
2. social anxiety.
3. obsessive-compulsive disorder.
4. performance anxiety.

Rationale 1: The final examination is a temporary event that is the cause of the anxiety. Once the examination is over, it is likely that the situational anxiety will end. Social anxiety is a fear of crowds. Performance anxiety is frequently referred to as stage fright. Although the situation presented required the student to perform on the exam, it is best defined as situational anxiety.

17

The most productive way of managing stress would be to

1. use a combined approach (drug use and nonpharmacological strategies).
2. use anxiolytics.
3. practice meditation.
4. determine the cause and address it accordingly.

Rationale 4: Stress is generally a symptom of an underlying disorder. It is more productive to uncover and address the cause than to treat the symptoms.

18

Which area of the brain is primarily responsible for maintaining sleep and wakefulness?

1. Reticular activating system
2. Cerebral cortex
3. Limbic system
4. Cerebellum

Rationale 1: The reticular activating system is responsible for sleeping and wakefulness. The limbic system is responsible for emotional expression, learning, and memory. The primary functions of the cerebral cortex and cerebellum do not include sleep and wakefulness.

19

Which drug category can be used for treating anxiety?

1. Antitussives
2. Anticoagulants
3. Seizure drugs
4. Antibiotics

Rationale 3: In addition to antidepressants, several other drug classes are used to treat anxiety, including seizure drugs. Antibiotics are used primarily for bacterial infections. Antitussives are used as cough suppressants. Anticoagulants are used to prevent blood clots from forming.

20

Benzodiazepines are often the drug of choice for managing anxiety and insomnia. Which statement best explains why?

1. Benzodiazepines are the most effective.
2. Benzodiazepines have the lowest risk of dependency and tolerance.
3. Benzodiazepines are most likely to be covered under insurance premiums.
4. Benzodiazepines are the most affordable.

Rationale 2: Benzodiazepines have a lower risk of dependency and tolerance than do other drugs used for anxiety and insomnia (such as the barbiturates). They are not necessarily more effective, affordable, or likely to be covered under insurance premiums. Although economics is an important factor in pharmacology, drug safety is essential for widespread use.

21

Which of the following common adverse effects of selective serotonin reuptake inhibitors (SSRIs) would be stressed by the nurse during patient discharge?

1. Drowsiness and coma
2. Weight gain and sexual dysfunction
3. Headache and nausea
4. Dry mouth and urine retention

Rationale 2: Although anticholinergic effects such as dry mouth and urine retention could occur, they are not as common as weight gain or sexual dysfunction. Headache is not a common adverse effect, and neither is drowsiness or coma. Overdoses will cause anxiety and restlessness (not drowsiness).

22

Which sleep stage accounts for about one-half of total sleep?

1. NREM sleep stage 1
2. NREM sleep stage 3
3. NREM sleep stage 2
4. NREM sleep stage 4

Rationale 3: NREM sleep stage 2 accounts for 45–55% of total sleep. The other stages are considerably less than half.

23

A patient taking which of the following medications should avoid foods high in tyramine?

1. MAOIs
2. SSRIs
3. Beta blockers
4. Benzodiazepines

Rationale 1: MAOIs and foods high in tyramine can produce a hypertensive crisis, and therefore should not be taken together.

24

Which statement regarding the use of zolpidem (Ambien) for insomnia is accurate?

1. Patients using Ambien should avoid foods that contain tyramine.
2. Ambien will take longer to produce an effect when taken with food.
3. Ambien is contraindicated during pregnancy, but can be taken by breastfeeding mothers.
4. Ambien is classified as a benzodiazepine.

Rationale 2: The absorption of Ambien is slowed when taken with food. It is classified as a nonbenzodiazepine CNS depressant. It is classified as pregnancy category B, and should be avoided by breastfeeding mothers. Patients using MAOIs (not Ambien) should avoid foods high in tyramine.

25

Which explanation best indicates why barbiturates are rarely used to treat anxiety and insomnia?

1. They have a greater associated cost.
2. They have a high risk of producing an allergic response.
3. They are seldom effective.
4. They produce many serious adverse effects.

Rationale 4: Barbiturates were the drug of choice for anxiety and insomnia prior to the discovery of safer drug alternatives. They can be effective, and are not necessarily more expensive. Allergic reactions can occur, but are rare, and are not a primary reason they are no longer used for anxiety and/or insomnia.

26

It is important for the nurse to obtain a thorough history from a patient who is experiencing anxiety. This history will help to distinguish Standard Text: Select all that apply.

1. the best method of pharmacotherapy.
2. whether the patient might benefit from individual or group therapy.
3. the category of anxiety disorder.
4. the region of the brain that is causing the anxiety disorder.
5. substances that might worsen anxiety.

Correct Answer: 1,2,5

Rationale 1: The health care provider must accurately diagnose the anxiety disorder, because treatment differs among the various types of anxiety disorders. Some anxiety disorders are debilitating and require effective pharmacotherapy.
Rationale 2: Some patients benefit from individual or group psychotherapy, which can help them identify and overcome the root causes of their worry and fear.
Rationale 5: When obtaining a comprehensive medication history during the initial patient assessment, the nurse should observe any substances the patient is taking that might worsen or cause anxiety symptoms. Sometimes discontinuing or substituting an alternate drug for these “anxiety-promoting” medications can lessen patient symptoms.

27

The patient is diagnosed with post-traumatic stress disorder. What will the nurse assess in this patient? Standard Text: Select all that apply.

1. Tachycardia
2. Extreme nervousness or panic attacks
3. A fear of crowds
4. A fear of exposure to germs
5. Hallucinations, nightmares, or flashbacks

Correct Answer: 1,2,5
Rationale 1: Tachycardia is a symptom of post-traumatic stress disorder.
Rationale 2: Extreme nervousness or panic attacks are symptoms of post-traumatic stress disorder.
Rationale 3: A fear of crowds is typical in social anxiety disorder.
Rationale 4: A fear of exposure to germs is typical of obsessive-compulsive disorder.
Rationale 5: In post-traumatic stress disorder the person re-experiences traumatic events, which can take the form of nightmares, hallucinations, or flashbacks.

28

A patient has been in the intensive care unit for a week receiving various procedures throughout the day and night. Currently the patient, though physiologically stable, is irritable and paranoid and complains of vivid dreams when dozing off to sleep. What are the best actions for the nurse to take at this time? Standard Text: Select all that apply.

1. Check the patient’s oxygen status.
2. Request an order for sleep medication.
3. Assess the patient’s vital signs.
4. Turn down the lights at night and reduce noise to a minimum.
5. Schedule all tests and procedures before 9 p.m. or after 7 a.m.

Correct Answer: 2,4,5
Rationale 1: The patient is physiologically stable.
Rationale 2: Since it is important for the patient to get rest, an order for sleep medication would be appropriate.
Rationale 3: It is not necessary to assess the patient’s vital signs, since the patient is physiologically stable.
Rationale 4: When deprived of REM sleep, people experience a sleep debt and become frightened, irritable, paranoid, and even emotionally disturbed. It is speculated that to make up for their lack of dreaming, these persons experience far more daydreaming and fantasizing throughout the day. It is important to institute measures that promote restful sleep.
Rationale 5: When deprived of REM sleep, people experience a sleep debt and become frightened, irritable, paranoid, and even emotionally disturbed. It is important to institute measures that promote restful sleep, which would include scheduling tests and procedures so as to not disturb the patient’s sleep.

29

A patient whose spouse recently died is having difficulty falling asleep and does not want to take any prescription medications to induce sleep. How should the nurse respond? Standard Text: Select all that apply.

1. “Walking 2-3 miles or engaging in some other exercise every morning can enhance sleep.”
2. “There are alternative methods to treat insomnia, such as yoga, meditation, and massage therapy.”
3. “Eating a large meal at bedtime will help induce sleep.”
4. “Avoid caffeinated beverages, nicotine, and alcohol immediately prior to bedtime.”
5. “Count sheep after lying down in order to enhance sleep.”

Correct Answer: 1,2,4
Rationale 1: Exercise therapy (except just prior to sleeping), nutrition therapy, and deep breathing are alternative treatments for insomnia.
Rationale 2: Acupuncture, aromatherapy, yoga, prayer, massage, meditation, biofeedback therapy, hypnosis, guided imagery, and music therapy are alternative treatments for anxiety and insomnia.
Rationale 3: Eating a large meal prior to bedtime is a secondary cause of insomnia.
Rationale 4: Amphetamines, cocaine, caffeinated beverages, corticosteroids, sympathomimetics, antidepressants, alcohol use, nicotine, and tobacco use are secondary causes of insomnia.
Rationale 5: There is no evidence that counting sheep at bedtime helps to induce sleep.

30

A patient who has recently experienced the loss of a spouse asks the nurse if there are any over-the-counter herbs or nonprescription medications that can be used to improve insomnia. How should the nurse respond to this patient? Standard Text: Select all that apply.

1. “Ginger root is commonly taken to improve sleep.”
2. “Ginkgo is an herb commonly taken to improve sleep.”
3. “Diphenhydramine (Benadryl) and doxylamine are over-the-counter meds sometimes taken to produce drowsiness.”
4. “Valerian and melatonin are herbs commonly taken to improve sleep.”
5. “Kava is an herb taken to improve sleep.”

Correct Answer: 3,4
Rationale 1: Ginger root is not used to improve sleep.
Rationale 2: Ginkgo is not used to improve sleep.
Rationale 3: Diphenhydramine and doxylamine are two antihistamines frequently used to produce drowsiness.
Rationale 4: An herbal product with demonstrated efficacy in promoting relaxation is valerian root. Supplemental melatonin, 0.5-3.0 mg at bedtime, is alleged to decrease the time required to fall asleep and to produce a deep and restful sleep.
Rationale 5: High doses of kava can damage the liver and should not be used unless recommended by a health care provider.

31

A patient who is complaining of anxiety and difficulty sleeping has asked what prescription medications would assist in getting to sleep. What would be appropriate responses? Standard Text: Select all that apply.

1. Diphenhydramine (Benadryl)
2. Valerian root
3. Ramelteon (Rozerem)
4. Flurazepam (Dalmane)
5. Zolpidem (Ambien)

Correct Answer: 3,4,5
Rationale 1: Diphenhydramine (Benadryl) can be obtained over the counter and does not need a prescription to obtain. It does promote getting to sleep.
Rationale 2: Valerian is an herbal product that does not need a prescription to obtain. It does promote getting to sleep.
Rationale 3: Rozerem is a newer, nonbenzodiazepine hypnotic approved to treat chronic insomnia in people who have problems falling asleep.
Rationale 4: Benzodiazepines are drugs of choice for generalized anxiety disorder and the short-term therapy of insomnia. Flurazepam (Dalmane) should be taken at bedtime because it quickly produces significant drowsiness.
Rationale 5: Ambien is a sedative-hypnotic approved for short-term treatment of insomnia.