# Situation: The nurse at a Rural Health Unit (RHU) holds a class for parents of young children on how children grow, think, and behave. Another mother says her 4-year-old daughter talks to an imaginary friend and tells stories that did not happen, such as seeing a flying dog. Which responses should the nurse include in her advice? 1. Accept the imaginary friend as a normal part of this age 2. Punish the child for lying so the habit does not continue 3. Gently help the child tell fantasy apart from real events 4. Refer the child to a child psychiatrist for assessment

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629425  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse at a Rural Health Unit (RHU) holds a class for parents of young children on how children grow, think, and behave.

Another mother says her 4-year-old daughter talks to an imaginary friend and tells stories that did not happen, such as seeing a flying dog. Which responses should the nurse include in her advice?
1. Accept the imaginary friend as a normal part of this age
2. Punish the child for lying so the habit does not continue
3. Gently help the child tell fantasy apart from real events
4. Refer the child to a child psychiatrist for assessment

## 보기

1. 1 and 4
2. 1 and 3 **✔ 정답**
3. 2 and 3
4. 1, 3 and 4

**정답: 2**

## 해설

In the preoperational stage, fantasy and reality blur, so tall tales are imagination rather than deliberate lying, and imaginary friends are normal. Parents respond calmly, accept the imaginary friend, and gently help the child separate fantasy from real events. Punishment and referral are not needed for these normal behaviors.

## 심화 해설

Preoperational Stage and Imaginary Companions

A 4-year-old child is in Piaget’s preoperational stage (roughly ages 2–7 years). During this period, thinking is dominated by magical thinking, animism, and egocentrism. The boundary between fantasy and reality is not yet firmly established, so a child may describe a flying dog or converse with an invisible friend without any intent to deceive. These behaviors reflect imagination and cognitive development, not dishonesty or psychopathology.

Key point! Imaginary companions are a normal developmental phenomenon in early childhood. Qualitative research on only children describes an imaginary companion as an invisible or personified entity the child creates, which often serves as a companion and plays a meaningful role in the child’s emotional life [1]. The child is not “lying” in the adult sense; the story is a product of fantasy blending with reality.

Why Punishment and Referral Are Inappropriate

Punishing the child for “lying” would be counterproductive. In the preoperational stage, the child cannot reliably distinguish intentional falsehood from imaginative play. Punishment may create shame or anxiety around self-expression without teaching the cognitive skill the child has not yet developed. Similarly, referral to a child psychiatrist is not indicated for an isolated imaginary friend or tall tale in a 4-year-old. These behaviors are typical unless they are accompanied by persistent distress, functional impairment, social withdrawal, or safety concerns.

Watch out! A single imaginary friend or fanciful story is not a red flag. Referral would be considered only if the behavior interferes with daily functioning, causes significant distress, or is paired with other concerning signs.

How Parents Can Respond

The nurse’s advice should include two complementary actions. First, accept the imaginary friend as a normal part of this age. Second, gently help the child tell fantasy apart from real events. This does not mean confronting or shaming the child. Instead, parents can acknowledge the imaginative play while calmly labeling what is real: “That sounds like a fun pretend story. Dogs cannot really fly, but it is fun to imagine.” This approach supports the child’s gradual development of reality testing without invalidating creativity.

| Response | Appropriate? | Rationale |
| --- | --- | --- |
| Accept the imaginary friend as normal | Yes | Imaginary companions are developmentally typical in the preoperational stage [1] |
| Punish the child for lying | No | Child is not deliberately lying; punishment harms emotional development |
| Gently help separate fantasy from reality | Yes | Supports emerging reality testing while preserving imaginative play |
| Refer to a child psychiatrist | No | Not indicated for normal imaginative behavior without impairment or distress |

Connection to Theory of Mind

Longitudinal evidence suggests that imaginary companions are associated with the development of theory of mind (ToM), the ability to understand that others have thoughts, beliefs, and perspectives different from one’s own . Children with imaginary companions may practice mental-state reasoning through their interactions with the companion. This further supports the view that imaginary companions are a constructive feature of social-cognitive growth rather than a deficit. Research also indicates that children with imaginary companions may attribute more agency to non-human items, reflecting their active engagement in animistic and imaginative thinking . These findings reinforce that the nurse should normalize the behavior and guide parents toward supportive, gentle reality orientation.

The correct combination is acceptance of the imaginary friend plus gentle assistance in distinguishing fantasy from reality. Punishment and psychiatric referral are not appropriate for this normal developmental behavior.References (research sources)

- [1]The role of imaginary companion in the life of only children: a qualitative study.Research articlePanah ZY, Mahmoodabadi HZ, Dehghani F. (2023) · DOI: 10.1186/s12888-023-05360-0

## 임상 시나리오

Imaginary Friends in the Preoperational StageNormal development, not lying or pathology
A 4-year-old is in Piaget's preoperational stage, where magical thinking and animism blur fantasy and reality. Tall tales and imaginary companions reflect imagination, not intentional deception.

Advise parents to accept the imaginary friend calmly and gently help the child distinguish fantasy from real events without shaming. These behaviors support cognitive and emotional development.

CautionDo not punish the child for 'lying' and do not refer for psychiatric evaluation unless there is persistent distress, functional impairment, or social withdrawal.

## 핵심 개념

- **Preoperational stage** — Piaget's stage from about 2 to 7 years when magical thinking, animism, and egocentrism dominate and fantasy blends with reality.
- **Imaginary companion** — A normal invisible or personified entity created by a young child that often serves as a playmate and supports emotional development.
- **Magical thinking** — A cognitive pattern in early childhood in which the child believes thoughts or wishes can influence real events.
- **Animism** — Attributing life-like qualities to inanimate objects, common during the preoperational stage.
- **Egocentrism** — The inability to see a situation from another person's perspective, characteristic of the preoperational stage.

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