A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

Choice A rationale:

Taking corrective measures to enforce hand hygiene should not be the first step. It is important to establish a baseline and understand the current situation through data collection and analysis before implementing corrective measures.

Choice B rationale:

Establishing methods for collecting data within the facility is a crucial first step. Gathering information about the current hand hygiene practices, compliance rates, and areas of improvement is essential for the audit process. Data collection provides a factual basis for identifying problems and implementing targeted interventions.

Choice C rationale:

Comparing the facility's data with the established criteria for hand hygiene is a subsequent step after data collection. This step helps in evaluating the current practices against the accepted standards and guidelines. However, it is not the first step in the audit process.

Choice D rationale:

Determining the accepted standards for hand hygiene is an essential first step. It involves researching and understanding the national and international guidelines, protocols, and recommendations related to hand hygiene. Knowing the standards helps the task force establish a benchmark against which the facility's practices can be evaluated. It provides a foundation for data collection and subsequent analysis.

• A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
• B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
• C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
• D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.