A child is diagnosed with Legg-Calvé-Perthes disease.
The nurse knows that a key focus of nursing care for this child is:

Choice A rationale

Lateral curvature of the spine, known as scoliosis, can occur in Duchenne muscular dystrophy (DMD) as a secondary complication due to progressive muscle weakness affecting the spinal support. However, it is not the primary or initial characteristic manifestation of the disease. The fundamental pathology of DMD is direct muscle fiber degeneration leading to weakness.

Choice B rationale

Joint inflammation is characteristic of inflammatory arthropathies, such as juvenile idiopathic arthritis. Duchenne muscular dystrophy is a primary myopathy, a disorder of muscle tissue itself, not a condition primarily involving inflammation of the joints. While secondary musculoskeletal issues can arise, joint inflammation is not a hallmark feature of the disease.

Choice C rationale

Duchenne muscular dystrophy is an X-linked recessive disorder characterized by the absence of dystrophin, a crucial protein for maintaining muscle fiber integrity. This leads to progressive degeneration of skeletal muscle fibers, resulting in escalating muscle weakness. This weakness typically manifests in early childhood, starting in the proximal muscles and gradually spreading, leading to loss of ambulation.

Choice D rationale

While severe muscle weakness in Duchenne muscular dystrophy can indirectly lead to some skeletal deformities over time, such as contractures and kyphoscoliosis, these are typically secondary consequences rather than primary manifestations. The direct and defining characteristic of the disease is the progressive degeneration and weakness of the muscles themselves.

Choice A rationale

Allowing a teenager with suicide ideation to keep personal belongings, especially sharp objects, presents an immediate and significant safety risk. Such items can be readily used for self-harm, undermining the primary goal of ensuring the patient's physical safety in a hospital environment. The environment must be strictly controlled to remove potential means of self-injury.

Choice B rationale

While continuous monitoring is crucial for a teenager with suicide ideation, checking on them every hour is insufficient. The inherent risk of self-harm requires constant, direct observation to intervene immediately if the teenager attempts to harm themselves. Hourly checks leave ample time for potential self-injurious behaviors to occur unsupervised.

Choice C rationale

A no-suicide contract, while sometimes used as a therapeutic tool, does not guarantee that a teenager will not harm themselves. It relies on the patient's commitment, which can be overridden by intense emotional distress or impulsive urges. This intervention should never replace stringent safety measures like continuous supervision and environmental control in an acute setting.

Choice D rationale

Removing any items that could be used for self-harm and providing continuous supervision are essential safety interventions. This creates a secure environment by eliminating immediate means of injury and ensures constant observation, allowing for immediate intervention during an emergent situation. This approach directly mitigates the risk of self-harm in a vulnerable patient.