A client who has been prescribed diphenhydramine for seasonal allergies reports drowsiness and dry mouth. What is the nurse's best response?

A. Improved kidney function:Sodium polystyrene sulfonate is a cation-exchange resin that works within the gastrointestinal tract and does not have a direct therapeutic effect on the nephrons. While lowering potassium can prevent cardiac complications of renal failure, the drug itself does not reverse underlying kidney pathology. It is a symptomatic treatment for electrolyte imbalance.

B. Decreased serum potassium levels:This medication works by exchanging sodium ions for potassium ions across the intestinal mucosa, which are then excreted in the feces. The primary therapeutic goal is the significant reduction of potentially cardiotoxic extracellular potassium levels. It is a standard intervention for managing non-emergent hyperkalemia.

C. Increased bowel motility:While the drug can sometimes be administered with a laxative to prevent impaction, its primary pharmacological mechanism is ion exchange, not peristaltic stimulation. In some cases, it can actually cause constipation if not managed correctly. Increased motility is a side effect or secondary effect rather than the primary anticipated outcome.

D. Elevated serum sodium levels:Because the resin releases sodium in exchange for potassium, a modest increase in serum sodium can occur as a side effect. However, this is a secondary consequence that the nurse monitors for safety rather than a goal they anticipate as a therapeutic success. The focus remains on the reduction of potassium.

A. Provide information about therapeutic touch and consult with the care team regarding its implementation:The nurse should respect patient autonomy and investigate evidence-based non-pharmacological options. Consulting with the multidisciplinary team ensures the therapy is safe and integrated into the overall clinical plan. This promotes patient-centered care while maintaining professional standards and safety.

B. Include therapeutic touch in the care plan without consulting the patient:Implementing any therapy without patient consent violates the ethical principle of autonomy and the legal requirement for informed consent. The care plan must be a collaborative effort between the provider and the client. Nurses must discuss all interventions before they are added to the chart.

C. Discourage the patient from pursuing non-conventional methods:Dismissing a patient's interest in complementary therapies can damage the therapeutic relationship and cause the patient to withhold information. If the therapy is safe, it can be a valuable adjunct to conventional pain management. The nurse should be an objective resource rather than a barrier.

D. Refer the patient to seek advice outside of the health care system:This approach fragments care and may lead the patient to seek unsafe or unregulated practitioners. The nurse's role is to facilitate safe integration within the healthcare system whenever possible. Directing the patient away prevents the clinical team from monitoring for interactions or outcomes.