# Situation: The nurse on an acute psychiatric unit uses psychoanalytic and developmental theories to understand clients' behavior. A 15-year-old girl on the adolescent unit stays up past midnight on her phone, and the nurse plans to teach her about sleep routines. Asked what might happen if she kept this up for a month, she describes only what happened last night and says, 'I can't know that; it hasn't happened.' She compares and orders real events accurately. According to Piaget's theory, which approach fits her present level of thinking?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630175  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: The nurse on an acute psychiatric unit uses psychoanalytic and developmental theories to understand clients' behavior.

A 15-year-old girl on the adolescent unit stays up past midnight on her phone, and the nurse plans to teach her about sleep routines. Asked what might happen if she kept this up for a month, she describes only what happened last night and says, 'I can't know that; it hasn't happened.' She compares and orders real events accurately. According to Piaget's theory, which approach fits her present level of thinking?

## 보기

1. Use a story about a sleepy character to model the routine
2. Discuss how the habit may affect her grades and mood
3. Give her a firm rule to follow without discussing reasons
4. Show her last week's sleep log next to her quiz scores **✔ 정답**

**정답: 4**

## 해설

Piaget's ages are typical, not guaranteed; teaching is matched to the level of thinking the person shows. She cannot reason about a hypothetical future but handles real events logically, which is concrete operational thinking despite her age, so concrete evidence from her own recent nights works better than a discussion of possible consequences.

## 심화 해설

Understanding the Adolescent’s Cognitive Level

The 15-year-old’s response reveals a specific way of thinking. When asked to imagine a future consequence, she says she cannot know it because it has not happened yet. However, she can compare and order real events accurately. This pattern is the hallmark of concrete operational thinking. Although Piaget’s stages are typically associated with certain age ranges, the actual level of reasoning a person demonstrates is more important than chronological age for planning care. A teenager may still rely on concrete operations when the topic is unfamiliar or when abstract hypothetical reasoning has not fully developed.

The teaching strategy must match the client’s present level of thinking, not her age. Because she cannot mentally manipulate a hypothetical future, discussing possible consequences such as mood changes or academic decline would be ineffective. Instead, the nurse should provide tangible evidence drawn from her own recent experiences. Showing last week’s sleep log next to her quiz scores gives concrete, real data that she can compare and order logically. This approach respects her current cognitive capacity while still teaching about sleep routines.

Watch out! A story about a sleepy character is appealing but remains symbolic and may not connect to her own behavior. A firm rule without reasons bypasses her ability to reason and does not promote understanding. Key point! Concrete operational thinkers need real, observable evidence from their own lives, not abstract discussions of what might happen in the future.

The evidence base supports this developmental perspective. A systematic review of health literacy in children aged 9–12 years identifies concrete operational thinking as a defining characteristic of that developmental period [3]. Although the client in this scenario is 15, her described reasoning matches this earlier stage. The review emphasizes that health information must be presented in ways that align with the child’s cognitive abilities, which is exactly what using a personal sleep log and quiz scores accomplishes. This is not about treating the adolescent as younger; it is about meeting her where she is cognitively.

| Approach | Why It Fits or Does Not Fit |
| --- | --- |
| Story about a sleepy character | Uses symbolic modeling; requires abstract transfer from character to self, which is difficult for concrete operational thinking |
| Discuss effects on grades and mood | Requires hypothetical future reasoning; client explicitly cannot imagine what has not happened |
| Firm rule without reasons | Ignores her capacity to reason logically about real events; does not build understanding |
| Show sleep log next to quiz scores | Provides concrete, real, comparable data from her own recent experience; fits her demonstrated logical ability |

The occupational therapy literature on sleep interventions also highlights the importance of matching interventions to the individual’s functional and cognitive context . While that review focuses on occupation-based approaches, the underlying principle is consistent: sleep-related teaching works best when it is grounded in the person’s actual daily patterns and observable outcomes. For this adolescent, a sleep log paired with quiz scores is a form of occupation-based, concrete feedback. It lets her see the relationship between sleep and performance without requiring her to imagine a hypothetical month-long consequence.

The nurse’s role is to assess the client’s current reasoning and select a teaching method that the client can actually use. In this case, concrete data from her own recent nights is the only option that aligns with her demonstrated ability to compare and order real events.References (research sources)

- [3]The constructs of health literacy in children: a systematic review.Meta-analysis/systematic reviewBakhtiarvand SZ, Rahaei Z, Sadeghian HA, Fatehi F, Soltani S, Zareiyan A, Nutbeam D. (2025) · DOI: 10.1186/s12889-025-24573-4

## 임상 시나리오

Teaching Adolescents at Concrete Operational LevelMatch teaching to actual reasoning, not age
When a client cannot reason about a hypothetical future but can compare and order real events accurately, they are functioning at the concrete operational level despite chronological age. Teaching must use tangible evidence from their own recent experiences.

For sleep teaching, show last week's sleep log next to quiz scores so the client can logically compare real data. Avoid discussing possible future consequences such as mood or grade changes, which requires abstract hypothetical reasoning she has not yet demonstrated.

CautionA story about a sleepy character is symbolic and may not connect to her own behavior. A firm rule without reasons bypasses her reasoning ability and does not promote understanding.

## 핵심 개념

- **Concrete operational stage** — Piaget's stage where a person can reason logically about real, observable events but cannot yet manipulate hypothetical or abstract future possibilities.
- **Hypothetical reasoning** — The ability to imagine and think through situations that have not actually occurred; a hallmark of formal operational thought.
- **Formal operational stage** — Piaget's final cognitive stage, typically emerging in adolescence, characterized by abstract and hypothetical thinking.
- **Sleep hygiene** — Habits and environmental factors that promote consistent, quality sleep, such as regular routines and limiting late-night screen use.
- **Developmentally appropriate teaching** — Matching educational content and methods to the learner's actual cognitive level rather than only their chronological age.

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