MCQ Quiz-Sedative-Hypnotics

MCQ Quiz: Sedative-Hypnotics

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Sedative-hypnotics are a class of drugs used to treat anxiety and sleep disorders, but their use is fraught with risks, including dependence, cognitive impairment, and next-day drowsiness. As pharmacists are on the front lines of dispensing these medications, a deep understanding of their pharmacology, risks, and appropriate patient counseling is vital. This quiz for PharmD students will test your knowledge of benzodiazepines, “Z-drugs,” and other agents used to promote sleep, ensuring you are prepared to manage these therapies safely and effectively.

1. The primary mechanism of action for both benzodiazepines and “Z-drugs” involves enhancing the effects of which neurotransmitter?

  • Serotonin
  • Dopamine
  • GABA (gamma-aminobutyric acid)
  • Norepinephrine

Answer: GABA (gamma-aminobutyric acid)

2. Benzodiazepines increase the ________ of the GABA-A receptor’s chloride channel opening, while barbiturates increase the ________.

  • Duration; Frequency
  • Frequency; Duration
  • Potency; Efficacy
  • Efficacy; Potency

Answer: Frequency; Duration

3. Which of the following medications is classified as a “Z-drug” hypnotic?

  • Lorazepam
  • Diazepam
  • Zolpidem
  • Phenobarbital

Answer: Zolpidem

4. “Z-drugs” (zolpidem, zaleplon, eszopiclone) are considered more selective than benzodiazepines for which subunit of the GABA-A receptor, leading to more sedative versus anxiolytic effects?

  • Alpha-2
  • Alpha-1
  • Beta-3
  • Gamma-2

Answer: Alpha-1

5. A key counseling point for a patient taking any sedative-hypnotic is to:

  • Take the medication in the middle of the night if they can’t fall back asleep.
  • Take the medication only after they are in bed and ready for a full night’s sleep.
  • Combine the medication with an alcoholic beverage to enhance its effect.
  • Plan to drive to work immediately after taking the dose.

Answer: Take the medication only after they are in bed and ready for a full night’s sleep.

6. A patient reports performing activities like eating or driving while not fully awake after taking their sleep medication. This is a complex sleep-related behavior associated with:

  • All antihistamines.
  • “Z-drugs” like zolpidem.
  • Melatonin supplements.
  • Ramelteon.

Answer: “Z-drugs” like zolpidem.

7. A major risk of combining a sedative-hypnotic with another CNS depressant, such as an opioid or alcohol, is:

  • Serotonin syndrome.
  • A hypertensive crisis.
  • Additive sedation and potentially fatal respiratory depression.
  • Severe kidney damage.

Answer: Additive sedation and potentially fatal respiratory depression.

8. Due to the risk of falls, confusion, and cognitive impairment, most traditional sedative-hypnotics are listed on which guideline as potentially inappropriate for older adults?

  • The CHEST guidelines for anticoagulation.
  • The JNC 8 guidelines for hypertension.
  • The Beers Criteria.
  • The GINA guidelines for asthma.

Answer: The Beers Criteria.

9. What is the specific reversal agent for a benzodiazepine overdose?

  • Naloxone
  • N-acetylcysteine
  • Flumazenil
  • Protamine sulfate

Answer: Flumazenil

10. Abrupt discontinuation of a benzodiazepine after long-term use can lead to:

  • A feeling of well-being.
  • A severe and potentially life-threatening withdrawal syndrome.
  • Improved sleep quality.
  • No significant effects.

Answer: A severe and potentially life-threatening withdrawal syndrome.

11. Ramelteon is a hypnotic that is unique because it acts as a(n):

  • Agonist at melatonin receptors (MT1 and MT2).
  • Antagonist at orexin receptors.
  • Agonist at the GABA-A receptor.
  • Inhibitor of histamine-1 receptors.

Answer: Agonist at melatonin receptors (MT1 and MT2).

12. Suvorexant is a newer hypnotic medication that promotes sleep by:

  • Enhancing the effects of GABA.
  • Blocking the wake-promoting effects of the orexin neuropeptide system.
  • Stimulating melatonin receptors.
  • Blocking histamine receptors.

Answer: Blocking the wake-promoting effects of the orexin neuropeptide system.

13. A key principle of using sedative-hypnotics for insomnia is to:

  • Use the highest effective dose for the longest possible duration.
  • Use them as first-line therapy before trying non-pharmacologic options.
  • Use the lowest effective dose for the shortest possible duration.
  • Prescribe them indefinitely for all patients with sleep complaints.

Answer: Use the lowest effective dose for the shortest possible duration.

14. Which over-the-counter products are commonly used for sleep and exert their effect through a CNS depressant mechanism (antihistaminic)?

  • Ibuprofen and naproxen.
  • Pseudoephedrine and phenylephrine.
  • Diphenhydramine and doxylamine.
  • Loperamide and bismuth subsalicylate.

Answer: Diphenhydramine and doxylamine.

15. A pharmacist practicing with “geriatric sensitivity” would be particularly concerned about prescribing a long-acting benzodiazepine like diazepam to an older adult due to:

  • Its high cost.
  • Its lack of efficacy.
  • The risk of drug accumulation, leading to next-day drowsiness and increased fall risk.
  • Its stimulant properties.

Answer: The risk of drug accumulation, leading to next-day drowsiness and increased fall risk.

16. What is the first-line, evidence-based recommendation for the treatment of chronic insomnia?

  • A prescription for a Z-drug.
  • A long-acting benzodiazepine.
  • Cognitive Behavioral Therapy for Insomnia (CBT-I).
  • An over-the-counter antihistamine.

Answer: Cognitive Behavioral Therapy for Insomnia (CBT-I).

17. Most prescription sedative-hypnotics are classified as which schedule of controlled substances?

  • Schedule II
  • Schedule III
  • Schedule IV
  • Schedule V

Answer: Schedule IV

18. A patient taking a sedative-hypnotic should be counseled to avoid which of the following activities until they know how the drug affects them?

  • Watching television.
  • Reading a book.
  • Driving or operating heavy machinery.
  • Eating a meal.

Answer: Driving or operating heavy machinery.

19. A pharmacist’s role in the “prevention” of sedative-hypnotic misuse includes:

  • Counseling on the risks of dependence and tolerance.
  • Checking the PDMP for signs of overlapping prescriptions.
  • Educating on non-pharmacologic sleep hygiene.
  • All of the above.

Answer: All of the above.

20. A patient reports that their zolpidem is no longer working as well as it used to. This is a sign of:

  • An allergic reaction.
  • Tolerance.
  • A drug-food interaction.
  • The medication reaching its peak effect.

Answer: Tolerance.

21. In which practice setting would a pharmacist be most likely to manage the tapering of a long-term benzodiazepine?

  • Nuclear pharmacy.
  • Ambulatory care clinic.
  • Sterile compounding facility.
  • Pharmaceutical industry.

Answer: Ambulatory care clinic.

22. The use of a “difficult conversations” framework would be helpful for a pharmacist who needs to:

  • Discuss the risks and benefits of continuing long-term sedative-hypnotic therapy with a patient.
  • Explain the price of a medication.
  • Tell a patient their prescription is ready.
  • Ask for a patient’s date of birth.

Answer: Discuss the risks and benefits of continuing long-term sedative-hypnotic therapy with a patient.

23. A key “human factors” issue related to Z-drugs is:

  • The similar names (zolpidem, zaleplon) can lead to look-alike/sound-alike errors.
  • The packaging is difficult to open.
  • The tablets are too large to swallow.
  • They are not available in a generic form.

Answer: The similar names (zolpidem, zaleplon) can lead to look-alike/sound-alike errors.

24. The service of “deprescribing” is particularly relevant to sedative-hypnotics because:

  • Long-term use in older adults often has risks that outweigh the benefits.
  • These medications should be taken for life.
  • They have no potential for withdrawal.
  • They are very safe in all patient populations.

Answer: Long-term use in older adults often has risks that outweigh the benefits.

25. A pharmacist is a leader when they:

  • Advocate for the implementation of a “sleep hygiene” education program as an alternative to hypnotic prescribing.
  • Insist that all patients with insomnia receive a prescription.
  • Refuse to discuss non-pharmacologic options.
  • Focus only on the speed of dispensing.

Answer: Advocate for the implementation of a “sleep hygiene” education program as an alternative to hypnotic prescribing.

26. The “antidote” flumazenil must be used with extreme caution because:

  • It can precipitate seizures in patients physically dependent on benzodiazepines.
  • It is a CNS stimulant.
  • It is not effective.
  • It has a very long half-life.

Answer: It can precipitate seizures in patients physically dependent on benzodiazepines.

27. A key “neurologic principle” of sleep is the balance between:

  • Wake-promoting systems (e.g., orexin, histamine) and sleep-promoting systems (e.g., GABA).
  • The central and peripheral nervous systems.
  • The sympathetic and parasympathetic nervous systems.
  • The right and left hemispheres of the brain.

Answer: Wake-promoting systems (e.g., orexin, histamine) and sleep-promoting systems (e.g., GABA).

28. Which of the following is a key component of good sleep hygiene?

  • Taking long naps late in the afternoon.
  • Using a smartphone or tablet in bed right before trying to sleep.
  • Maintaining a consistent sleep-wake schedule, even on weekends.
  • Consuming a large meal and caffeine right before bed.

Answer: Maintaining a consistent sleep-wake schedule, even on weekends.

29. The use of a “Clinical Decision Support” alert in an EHR would be most appropriate to fire when:

  • A prescriber orders a benzodiazepine for an elderly patient who is also taking an opioid.
  • A patient is due for a flu shot.
  • A patient’s insurance information is updated.
  • A non-controlled medication is refilled.

Answer: A prescriber orders a benzodiazepine for an elderly patient who is also taking an opioid.

30. The ultimate goal of treating insomnia is to:

  • Ensure the patient remains on a hypnotic for the rest of their life.
  • Improve sleep quality and daytime functioning while minimizing risks from therapy.
  • Find the highest possible dose of medication the patient can tolerate.
  • Eliminate the need for sleep entirely.

Answer: Improve sleep quality and daytime functioning while minimizing risks from therapy.

31. Barbiturates are rarely used as hypnotics today due to their:

  • High therapeutic index.
  • Low potential for abuse.
  • High lethality in overdose and narrow therapeutic index.
  • Lack of efficacy.

Answer: High lethality in overdose and narrow therapeutic index.

32. The “forging ahead” mindset in pharmacy means viewing insomnia not just as a prescription to be filled, but as:

  • An opportunity to provide comprehensive patient care, including education on sleep hygiene and deprescribing when appropriate.
  • A simple problem with a simple solution.
  • A condition that is not the pharmacist’s concern.
  • A way to increase pharmacy sales.

Answer: An opportunity to provide comprehensive patient care, including education on sleep hygiene and deprescribing when appropriate.

33. An “analytics and reporting system” could be used to improve safety by:

  • Identifying patients who are receiving prescriptions for both opioids and benzodiazepines from different prescribers.
  • Tracking the pharmacy’s daily profits.
  • Ordering medications.
  • Generating a marketing report.

Answer: Identifying patients who are receiving prescriptions for both opioids and benzodiazepines from different prescribers.

34. A “business plan” for a new pharmacist-led insomnia clinic would need to include a strong emphasis on:

  • A “prescription-first” approach.
  • Non-pharmacologic services like CBT-I and sleep hygiene education.
  • Selling high-margin sleep supplements.
  • A rapid patient turnover model.

Answer: Non-pharmacologic services like CBT-I and sleep hygiene education.

35. A pharmacist’s knowledge of “human resources” is relevant when:

  • A pharmacy technician is impaired on the job due to misuse of a sedative-hypnotic.
  • The pharmacy is deciding on a new computer system.
  • A patient asks about the price of a medication.
  • The pharmacy needs to order more vials.

Answer: A pharmacy technician is impaired on the job due to misuse of a sedative-hypnotic.

36. A key part of “gerotechnology” could be:

  • A bed sensor that monitors an older adult’s sleep patterns and fall risk.
  • A smartphone that is too complex for an older adult to use.
  • A standard television.
  • A landline telephone.

Answer: A bed sensor that monitors an older adult’s sleep patterns and fall risk.

37. From a “policy” perspective, the reclassification of carisoprodol (a muscle relaxant with sedative properties) as a controlled substance was a response to:

  • Its widespread abuse.
  • Its high cost.
  • Its lack of efficacy.
  • A request from the manufacturer.

Answer: Its widespread abuse.

38. The use of “negotiation” skills might be required when:

  • A pharmacist is discussing a tapering plan for a benzodiazepine with a patient who is reluctant to stop.
  • A patient is picking up a routine refill.
  • A pharmacist is ringing up a sale at the register.
  • A pharmacist is checking in a medication order.

Answer: A pharmacist is discussing a tapering plan for a benzodiazepine with a patient who is reluctant to stop.

39. The “regulation” of sedative-hypnotics by the DEA is based on their:

  • Therapeutic efficacy.
  • Potential for abuse and psychological/physical dependence.
  • Cost.
  • Mechanism of action.

Answer: Potential for abuse and psychological/physical dependence.

40. The “marketing” of new hypnotic agents often focuses on:

  • Their high potential for abuse.
  • A novel mechanism of action or a potentially improved safety profile compared to older agents.
  • Their low cost.
  • Their ability to be used for long-term, chronic therapy.

Answer: A novel mechanism of action or a potentially improved safety profile compared to older agents.

41. Which of the following is a long-acting benzodiazepine?

  • Alprazolam
  • Lorazepam
  • Diazepam
  • Triazolam

Answer: Diazepam

42. A pharmacist’s understanding of “health disparities” is important because:

  • Access to non-pharmacologic treatments like CBT-I may be limited in underserved populations.
  • All patient populations use sedative-hypnotics at the same rate.
  • Insurance coverage for these medications is the same for everyone.
  • The side effect profiles are the same in all ethnic groups.

Answer: Access to non-pharmacologic treatments like CBT-I may be limited in underserved populations.

43. The “services” a modern pharmacy offers should include:

  • Comprehensive counseling on the safe use of sedative-hypnotics.
  • Education on sleep hygiene.
  • Screening for potential misuse or abuse.
  • All of the above.

Answer: All of the above.

44. A key part of the “Introduction to Pharmacy Informatics” is understanding how the PDMP works as a tool to:

  • Prevent unsafe use of controlled substances like sedative-hypnotics.
  • Increase the sales of these medications.
  • Make prescribing easier.
  • Replace the EHR.

Answer: Prevent unsafe use of controlled substances like sedative-hypnotics.

45. An “Electronic Health Record” improves the safe use of hypnotics by:

  • Providing a clear record of a patient’s history of use.
  • Alerting prescribers to potential drug interactions.
  • Allowing for easy tracking of renal and hepatic function.
  • All of the above.

Answer: All of the above.

46. A “human factors” approach to the labeling of sedative-hypnotics would emphasize:

  • Clear, unambiguous warnings about avoiding alcohol and driving.
  • Small, difficult-to-read font.
  • Vague language about side effects.
  • A focus on the brand name only.

Answer: Clear, unambiguous warnings about avoiding alcohol and driving.

47. A “first response” to an individual who is unconscious after taking a “downer” should prioritize:

  • Identifying the substance.
  • Ensuring the person is breathing and calling for help.
  • Administering a reversal agent immediately.
  • Finding out who gave them the drug.

Answer: Ensuring the person is breathing and calling for help.

48. A pharmacist’s understanding of “cardiovascular principles” is relevant because:

  • Many sedative-hypnotics can cause hypotension, especially in overdose.
  • These drugs are first-line for treating hypertension.
  • They have no effect on the cardiovascular system.
  • They are known to strengthen heart muscle contraction.

Answer: Many sedative-hypnotics can cause hypotension, especially in overdose.

49. The use of “antipsychotics” like quetiapine at low doses for insomnia is:

  • A first-line, FDA-approved indication.
  • A common off-label use that is controversial due to the risk of side effects.
  • A safe and effective strategy for all patients.
  • The preferred treatment for geriatric insomnia.

Answer: A common off-label use that is controversial due to the risk of side effects.

50. The ultimate principle for a pharmacist managing sedative-hypnotic therapy is to:

  • Promote patient safety by ensuring appropriate use and minimizing risks.
  • Ensure the patient remains on the medication indefinitely.
  • Fill every prescription as written without question.
  • Prioritize pharmacy profits over patient well-being.

Answer: Promote patient safety by ensuring appropriate use and minimizing risks.

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