The Ill Child in the Hospital and Other Care Settings

Which play activity should the nurse implement to enhance deep breathing exercises for a toddler? a. Blowing bubbles b. Throwing a Nerf ball c. Using a spirometer d. Keeping a chart of deep breathing

ANS: A Age-appropriate play for a toddler to enhance deep breathing is blowing bubbles. Throwing a Nerf ball does not enhance deep breathing. Using a spirometer and keeping a chart of deep breathing are more appropriate for a school-age child.

The nurse notes that the parents of a child in the intensive care unit (ICU) seem to spend a lot of time talking with the parents of another child who is in the ICU. How should the nurse best interpret this behavior? a. Parent-to-parent support is valuable. b. Parent-to-parent dependence is unhealthy. c. A situation has developed because the parents are unhappy with the care. d. This situation has the potential to increase friction between the parents and staff.

ANS: A Parent-to-parent support is unique and not available from other sources. Being with other parents who have shared similar experiences (hospitalization, etc.) allows a mutually supportive environment. Rather than being a dependent relationship, parents provide support for each other. There is no data to say the parents are unhappy with the care. It is becoming increasingly common for parent-to-parent interaction to be facilitated by hospitals.

How should the nurse advise parents whose preschooler used to sleep through the night and now awakens at intervals after a short hospitalization? a. Regressive behavior after a hospitalization is normal and usually short term. b. The child is probably expressing anger. c. Egocentric behavior often manifests itself when the child is left alone to sleep. d. The child is probably feeling pain and needs further evaluation.

ANS: A Regression is manifested in a variety of ways, is normal, and usually is short term. Nighttime waking is not associated with anger. Egocentric behavior is not an explanation for nighttime waking. More information is needed before assessment of pain can be made.

A 3-year-old child cries, kicks, and clings to the father when the parents try to leave the hospital room. What is the nurse's best response to the parents about this behavior? a. "Your child is showing a normal response to the stress of hospitalization." b. "Your child is not coping effectively with hospitalization." c. "Parents should stay with children during hospitalization." d. "You can avoid this if you leave after your child falls asleep."

ANS: A The child is exhibiting a healthy attachment to the father. The child's behavior represents the protest stage of separation and does not represent maladaptive behavior. This response places undue stress and guilt on the parents. Leaving when the child is asleep will foster mistrust.

Which is the most developmentally appropriate intervention when working with the hospitalized adolescent? a. Encourage peers to call and visit when the adolescent's condition allows. b. Encourage the adolescent's friends to continue with their daily activities; the adolescent has concrete thinking and will understand. c. Discourage questions and concerns about the effects of the illness on the adolescent's appearance. d. Ask the parents how the adolescent usually copes in new situations.

ANS: A The peer group is important to the adolescent's sense of belonging and identity; therefore separation from friends is a major source of anxiety for the hospitalized adolescent. Adolescents should have advanced beyond concrete thinking. In addition, hospitalized adolescents may be upset if their friends continue with daily activities without them. Communication, interacting, and meeting with friends will be important. Questions and concerns should be encouraged regarding the adolescent's appearance and the effects of illness on appearance. How the adolescent copes should be asked directly of the adolescent.

A nurse is working with a child who has a sudden, serious illness. To best support the parents, what action by the nurse is best? a. Assess the parents' usual coping methods. b. Give them information about the unit protocols. c. Tell them to stay with the child as much as desired. d. Reassure them about how common this illness is.

ANS: A The way these parents will cope with this sudden illness is the same as how they cope with other stressors. The nurse helps the parents identify coping methods and support systems. Giving information about the unit and telling them they can stay are positive interventions but too narrow in scope to be the best answer. Reassuring them that their child's illness is common belittles their concerns.

The nurse is working with a child in the intensive care unit. The family is from out of town. There are two siblings, both of whom are acting out at home. What suggestions does the nurse provide the family? (Select all that apply.) a. Let the siblings call the ill child at scheduled times. b. Take photographs of the sick child to show the siblings. c. Suggest the parents take the siblings to counseling. d. Reassure the siblings that they will not get ill themselves. e. Stay at home with the siblings until their behavior improves.

ANS: A, B, D Having siblings call or visit the sick child helps them cope with the situation and can ease anxiety. If the sibling fears a similar illness, parents can reassure them this will not happen if reasonable. Going to counseling may be needed if the siblings cannot be reassured but is not the first step as this is normal behavior. The parents may become overly stressed if told to stay at home.

The traditional areas of school health nursing that are still prevalent in many school systems include which of the following? (Select all that apply.) a. Health screening b. Emergency care c. Intensive care d. Communicable disease management e. Health care advice

ANS: A, B, D, E Health screening such as vision, hearing, and growth checks can provide information about problems that may affect the child's ability to learn. School nurses are often the first to provide care for children experiencing an unintentional injury, either on the playground or in the school building. The nurse must assess children for illnesses that may be transmitted to other children and provide care and isolation until a parent can pick up the child from school. The school nurse can be a source of referral for families in need of health care services. Intensive care is provided in the hospital.

What are age-appropriate nursing interventions to facilitate psychological adjustment for an adolescent expected to have a prolonged hospitalization? (Select all that apply.) a. Encourage parents to bring in homework and schedule study times. b. Allow the adolescent to wear street clothes. c. Involve the parents in care. d. Follow home routines. e. Encourage parents to bring in favorite foods.

ANS: A, B, E Completing homework during study time, allowing the teen to wear street clothes, and encouraging parents to bring favorite foods are all age appropriate. Involving parents in care and following home routines are important interventions for the preschool child who is in the hospital. Adolescents do not need parents to assist in their care. They are used to performing independent self-care. Adolescents may want their parents to be nearby, or they may enjoy the freedom and independence from parental control and routines.

The nurse educator is providing information to a group of new nurses in a pediatric hospital. What information should the nurse include regarding the care of hospitalized preschoolers? Select all that apply. a. Their thinking is egocentric. b. Children this age express feelings of shame and guilt. c. Preschoolers need to have some control of their hospital day. d. Children this age like to have a variety of areas to roam or use unless very ill. e. Home bedtime routines should be avoided in the hospital because of possible confusion. f. The child may be able to relate perceptions of what is happening by the use of drawings.

ANS: A, C, D, F Preschoolers have egocentric thinking. It is very important to allow preschoolers some control of their hospital day whether it's which juice for their medications, when they bathe, or whatever choices are appropriate and reasonable to allow them to have. Children this age like to have a variety of areas to roam or use unless very ill. The child may be able to relate perceptions of what is happening by the use of drawings. Children this age do not easily express feelings of shame and guilt. Home bedtime routines should be used to provide continuity when in the hospital.

In which age-group does the child's active imagination during unfamiliar experiences increase the stress of hospitalization? a. Toddlers b. Preschoolers c. School-age children d. Adolescents

ANS: B Active imagination is a primary characteristic of preschoolers. A toddler's primary response to hospitalization is separation anxiety. School-age children experience stress with loss of control. Adolescents experience stress from separation from their peers.

Why is observation for 24 hours in an acute-care setting often appropriate for children? a. Longer hospital stays are more costly. b. Children become ill quickly and recover quickly. c. Children feel less separation anxiety when hospitalized for 24 hours. d. Families experience less disruption during short hospital stays.

ANS: B Children become ill quickly and recover quickly; therefore they can require acute care for a shorter period of time. A child's state of wellness, rather than cost, determines the length of stay. Separation anxiety is primarily a factor of the stage of development, not the length of hospital stay. Family disruption is a secondary outcome of a child's hospitalization; it does not determine length of stay.

Which situation poses the greatest challenge to the nurse working with a child and family? a. Twenty-four-hour observation b. Emergency hospitalization c. Outpatient admission d. Rehabilitation admission

ANS: B Emergency hospitalization involves (1) limited time for preparation both for the child and family, (2) situations that cause fear for the family that the child may die or be permanently disabled, and (3) a high level of activity, which can foster further anxiety. Although preparation time may be limited with a 24-hour observation, this situation does not usually involve the acuteness of the situation and the high levels of anxiety associated with emergency admission. Outpatient admission generally involves preparation time for the family and child. Because of the lower level of acuteness in these settings, anxiety levels are not as high. Rehabilitation admission follows a serious illness or disease. This type of unit may resemble a home environment, which decreases the child's and family's anxiety.

A toddler's parents have had to leave him for several days during his hospitalization. Which behavior by the toddler should the nurse identify as demonstration of the protest phase of separation anxiety? a. Lack of activity b. Clinging to parent c. Depression-sadness d. Regression to earlier behavior

ANS: B In the protest phase, the child aggressively responds to separation from parents. Inactivity is characteristic of despair. Depression-sadness is characteristic of despair. Regression to earlier behavior is characteristic of despair.

A nurse needs to start an intravenous (IV) line on an 8-year-old to begin administering IV antibiotics. The child starts to cry and tells the nurse, "Do it later, okay?" Which response by the nurse is the most appropriate one by the nurse? a. "I need to start the IV right now because your doctor ordered it to get you better." b. "Do you want ice cream or a sandwich after you get your IV started?" c. "Do you want the IV started now or in an hour after you eat something?" d. "You let me know when you're ready for me to start your IV."

ANS: B Intravenous antibiotics are a priority action for the nurse. Giving the child a choice about some aspect such as a treat after the IV allows the child some control over the situation during the hospital experience. The child doesn't care who ordered it. The child needs to have some control over the hospital experience. If the timing of the start of IV antibiotics is not essential, it might be acceptable to delay. The nurse should recognize that the child may never be "ready." The anxiety is likely to increase with prolonged delay.

Which question most likely elicits information about how a family is coping with a child's hospitalization? a. "Was this admission an emergency?" b. "How has your child's hospitalization affected your family?" c. "Who is taking care of your other children while you are here?" d. "Is this the child's first hospitalization?"

ANS: B Open-ended questions encourage communication. Ensuring a positive outcome from the hospital experience can be optimized by the nurse addressing the health needs of family members, as well as the needs of the child. Asking closed-ended questions inhibits communication.

Based on concepts related to the normal growth and development of children, which child would have the most difficulty with separation from family during hospitalization? a. A 5-month-old infant b. A 15-month-old toddler c. A 4-year-old child d. A 7-year-old child

ANS: B Separation is the major stressor for children hospitalized between ages 6 and 30 months. Infants younger than 6 months of age will generally adapt to hospitalization if their basic needs for food, warmth, and comfort are met. Although separation anxiety occurs in hospitalized preschoolers, it is usually less obvious and less serious than that experienced by the toddler. The school-age child is accustomed to separation from parents. Although hospitalization is a stressor, the 7-year-old child will have less separation anxiety than a 15-month-old toddler.

A child with a serious, chronic illness is hospitalized frequently. The parents are worried about the child's growth and development. What action by the nurse is best? a. Tell parents developmental delays are likely in this case. b. Make a referral to the play therapist for therapeutic play. c. Encourage the child to perform age-appropriate activities. d. Ask the parents if they want a child psychology referral.

ANS: B Since developmental delay is a high risk in this situation, the nurse consults with the play therapist for therapeutic play interventions. Encouraging age-appropriate activities is always important but does not address this concern. The child may need a psychology referral, but that is not the first step. Telling parents that delays are likely in this case is discouraging and does not offer any positive solutions.

The nurse is arranging transfer of a 6-year-old child with acute renal failure from intensive care to a regular pediatric unit. With which child should the nurse place this child? a. A 6-year-old with pneumonia b. A 5-year-old with a fractured femur c. A 4-year-old who has gastroenteritis d. A 7-year-old recovering from surgery for a ruptured appendix

ANS: B The 5-year-old orthopedic patient would be the best choice for a roommate. This child does not have an illness of viral or bacterial origin. The 6-year-old who has pneumonia has a potentially infectious disease process. The 4-year-old who has gastroenteritis has a potentially infectious disease process. The 7-year-old child who had surgery for a ruptured appendix has a potentially infectious disease process.

A hospitalized toddler clings to a worn, tattered blanket and screams whenever anyone tries to take the blanket away. What explanation for her attachment to the blanket should the nurse remembering using developmental theory? a. The blanket encourages immature behavior. b. The blanket is an important transitional object. c. The toddler has not bonded adequately with her mother. d. The developmental task of individuation-separation has not been mastered.

ANS: B The blanket is an important transitional object that provides security when the child is separated from the parents. Transitional objects are important to help toddlers feel secure and do not encourage immature behavior. There is no data that supports the toddler has not bonded adequately with her mother. Mastering the task of individuation-separation does not reflect bonding behavior.

A preschool-aged child tells the nurse "I was bad, that's why I got sick." What is the best rationale for this child's statement? a. The child has a fear that mutilation will lead to death. b. The child's imagination is very active, and he may believe the illness is a result of something he did. c. The child has a general understanding of body integrity at this age. d. The child will not have fear related to an IV catheter initiation but will have fear of an impending surgery.

ANS: B The child may believe that an illness occurred as a result of some personal deed or thought or perhaps because he touched something or someone. The child has imaginative thoughts at this stage of growth and development. Preschoolers do not have the cognitive ability to connect mutilation to death and do not have a sound understanding of body integrity. The preschooler fears all types of intrusive procedures, whether undergoing a simple procedure such as an IV start or something more invasive such as surgery.

The nurse is working with families and their children in an outpatient surgical center. What information about the family and the surgical experience is most important for the nurse to consider when working with these families? a. Anxiety is minimal for both parents and the child in such a center. b. Waiting during surgery is not as stressful for parents in such a center. c. Families need to be prepared for what to expect after discharge. d. Accurate and complete discharge teaching is the responsibility of the surgeon.

ANS: C Discharge instructions should be provided in both written and oral forms. They need to include which responses to the procedure are normal, when to notify the practitioner if untoward reactions are occurring, and when to return to the center. Although anxiety may be reduced because of the lack of an overnight stay, the child will still feel the stress associated with a medical procedure. The waiting period while the child is having the procedure is a very stressful time for families. Discharge teaching is a responsibility of both the surgeon and the nursing staff.

What is the best action for the nurse to take when a 5-year-old child who requires another 2 days of IV antibiotics cries, screams, and resists having the IV restarted? a. Exit the room and leave the child alone until he or she stops crying. b. Tell the child big boys and girls "don't cry." c. Let the child decide which color arm board to use with the IV. d. Administer an opioid analgesic for pain to quiet the child.

ANS: C Giving the preschooler some choice and control, while maintaining boundaries of treatment, supports the child's coping skills. Leaving the child alone robs the child of support when a coping difficulty exists. Crying is a normal response to stress. The child needs time to adjust and support to cope with unfamiliar and painful procedures during hospitalization. Although administration of a topical analgesic is indicated before restarting the child's IV, an opioid analgesic is not indicated.

What is the best explanation for a 2-year-old child who is quiet and withdrawn on the fourth day of a hospital admission? a. The child is protesting her separation from her caregivers. b. The child has adjusted to the hospitalization. c. The child is experiencing the despair stage of separation. d. The child has reached the stage of detachment.

ANS: C In the despair stage of separation, the child exhibits signs of hopelessness and becomes quiet, withdrawn, and apathetic. In the protest stage, the child would be agitated, crying, resistant to caregivers, and inconsolable. Toddlers do not readily "adjust" to hospitalization and separation from caregivers. The detachment stage occurs after prolonged separation. During this phase, the child becomes interested in the environment and begins to play.

Which therapeutic approach will best help a 7-year-old child cope with a lengthy course of intravenous antibiotic therapy? a. Arrange for the child to go to the playroom daily. b. Ask the child to draw you a picture of himself or herself. c. Allow the child to participate in injection play. d. Give the child stickers for cooperative behavior.

ANS: C Injection play is an appropriate intervention for the child who has to undergo frequent blood work, injections, intravenous therapy, or any other therapy involving syringes and needles. The hospitalized child should have opportunities to go to the playroom each day if the child's condition warrants. This free play does not have any specific therapeutic purpose. Children can express their thoughts and beliefs through drawing. Asking the child to draw a picture of himself or herself may not elicit the child's feelings about the treatment. Rewards such as stickers may enhance cooperative behavior. They will not address coping with painful treatments.

The nurse is explaining common fears to a group of preschool parents. It is important for the nurse to explain that the psychosexual conflicts of preschool children make them extremely vulnerable to which threat? a. Separation anxiety b. Loss of control c. Bodily injury and pain d. Loss of identity

ANS: C Intrusive procedures, regardless of whether they are perceived as painful, are threatening to the preschool child because of the poorly developed concept of body integrity. Separation anxiety is a characteristic of infants and toddlers. Loss of control is a characteristic fear of school-age children. Loss of identity is a concern of adolescents, because illnesses are conceptualized as the effect on the individual.

Home care is being considered for a young child who is ventilator dependent. Which factor is most important in deciding whether home care is appropriate? a. Level of parents' education b. Presence of two parents in the home c. Preparation and training of family d. Family's ability to assume all health care costs

ANS: C One of the essential elements is the training and preparation of the family. The family must be able to demonstrate all aspects of care for the child. In many areas, it cannot be guaranteed that nursing care will be available on a continual basis, and the family will have to care for the child. The amount of formal education reached by the parents is not the important issue. The determinant is the family's ability to care adequately for the child in the home. At least two family members should learn and demonstrate all aspects of the child's care in the hospital, but it does not have to be two parents.

What is the primary disadvantage associated with outpatient and day facility care? a. Increased cost b. Increased risk of infection c. Lack of physical connection to the hospital d. Longer separation of the child from family

ANS: C Outpatient and day facility care do not provide extended care; therefore a child requiring extended care should be transferred to the hospital, causing increased stress to the child and parents. This type of care decreases cost and infection and minimizes separation between the child and family.

The parents of a 4-year-old child who is scheduled for cardiac surgery next week call the hospital and ask how to prepare their child for surgery. What information should the nurse use when replying to the parents? a. Preparation at this age will only increase the child's stress. b. Preparation should have begun at least 2 to 3 weeks before hospitalization. c. Children who are prepared demonstrate less fear and stress during hospitalization. d. Children who are prepared demonstrate overwhelming fear by the time hospitalization occurs.

ANS: C Preparing the child for the hospitalization will reduce the number of unknown elements. Taking a tour, handling some of the equipment, or being told stories about what to expect will increase the child's familiarity with items. Preparation will reduce stress by allowing the child to incorporate the threat more slowly. For this age group, 1 week of preparation is recommended. A reduction in fear is usually observed.

Having explanations for all procedures and selecting their own meals from hospital menus is an important coping mechanism for which age-group? a. Toddlers b. Preschoolers c. School-age children d. Adolescents

ANS: C School-age children are developmentally ready to accept detailed explanations. School-age children can select their own menus and become actively involved in other areas of their care. Toddlers need routine and parental involvement for coping. Preschoolers need simple explanations of procedures. Detailed explanations and support of peers help adolescents cope.

Which is an appropriate nursing intervention for the hospitalized neonate? a. Assign the neonate to a room with other neonates. b. Provide play activities in the hospital room. c. Offer the neonate a pacifier between feedings. d. Request that parents bring a security object from home.

ANS: C The neonate needs opportunities for nonnutritive sucking and oral stimulation with a pacifier. The neonate is not aware of other children. The choice of roommate will not affect the neonate socially. It is important for older children to room with similar-age children. Formal play activities are not relevant for the neonate. Having parents bring a security object from home is applicable to older children.

What should the nurse advise the mother of a 4-year-old child to bring with her child to the outpatient surgery center on the day of surgery? a. Snacks b. Fruit juice boxes c. All of the child's medications d. One of the child's favorite toys

ANS: D A familiar toy can be effective in decreasing a child's stress in an unfamiliar environment. The child will be NPO before surgery; therefore including snacks for the child is contraindicated. The child will be NPO before surgery. Unnecessary stress will result when the child is denied the juice. It is not necessary to bring all medications on the day of surgery. The medication the child has been receiving should have been noted during the preoperative workup. The parent should be knowledgeable of which medications the child has been taking if further information is necessary.

A 3 1/2-year-old child who is toilet trained has had several "accidents" since hospital admission. What is the nurse's best action in this situation? a. Find out how long the child has been toilet trained at home. b. Encourage the parents to scold the child. c. Explain how to use a bedpan and place it close to the child. d. Follow home routines of elimination.

ANS: D Cooperation will increase and anxiety will decrease if the child's normal routine and rituals are maintained. Some regression to previous behaviors is normal during hospitalization, even when the child has been practicing the skill for some time. Hospitalization is a stressful experience. If the incontinence is caused by anxiety, scolding is not indicated and may increase the anxiety. Developmentally, the 3 1/2-year-old child cannot use a bedpan independently.

Which intervention helps a hospitalized toddler feel a sense of control? a. Assign the same nurses to care for the child. b. Put a cover over the child's crib. c. Require parents to stay with the child. d. Follow the child's usual routines for feeding and bedtime.

ANS: D Familiar rituals and routines are important to toddlers and give the child a sense of control. Following the child's usual routines during hospitalization minimizes feelings of loss of control. Providing consistent caregivers is most applicable for the very young child, such as the neonate and infant. Placing a cover over the child's crib may increase feelings of loss of control. Parents are encouraged, rather than expected, to stay with the child during hospitalization.

The home health nurse outlines short- and long-term goals for a 10-year-old child with many complex health problems. Who should agree on these goals? a. Family and nurse b. Child, family, and nurse c. All professionals involved d. Child, family, and all professionals involved

ANS: D In the home, the family is a partner in each step of the nursing process. The family priorities should guide the planning process. Both short-term and long-term goals should be outlined and agreed on by the child, family, and professionals involved. Involvement of the individuals who are essential to the child's care is necessary during this very important stage. The elimination of any one of these groups can potentially create a plan of care that does not meet the needs of the child and family.

What is the best nursing response to the mother of a 4-year-old child who asks what she can do to help the child cope with a sibling's repeated hospitalizations? a. Recommend that the child be sent to visit the grandmother until the sibling returns home. b. Inform the parent that the child is too young to visit the hospital. c. Assume the child understands that the sibling will soon be discharged because the child asks no questions. d. Help the mother give the child a simple explanation of the treatment, and encourage the mother to have the child visit the hospitalized sibling.

ANS: D Needs of a sibling will be better met with factual information and contact with the ill child. Separation from family and home may intensify fear and anxiety. Parents are experts on their children and need to determine when their child can visit a hospital. Children may have difficulty expressing questions and fears and need the support of parents and other caregivers.

A young child's parents have left her during hospitalization. Which stage of separation anxiety would the nurse expect to see first? a. Denial b. Despair c. Detachment d. Protest

ANS: D Protest is the first stage of separation anxiety. Denial is not a stage of separation anxiety. The second stage of separation anxiety is despair. Detachment is the third stage of separation anxiety.

The parents of a child who is ventilator dependent tell the nurse that their insurance company wants their child discharged. The parents tell the nurse that they do not want their child home "under any circumstances." Which factor is most important in working with this family? a. The level of the parents' education b. Presence and training of the two parents in the home c. The family's ability to assume all health care expenses d. The reason(s) why the family does not want the child at home

ANS: D The nurse should elicit an explanation from the parents about why they do not want the child at home. After this assessment is complete, then potential interventions can be examined. Without parental desire and capability, quality home care cannot be provided for the child. The community must have adequate resources available as well, which include capable professional support. The level of the parents' education is not the most important issue. A minimum of two family members should learn and be able to demonstrate their ability to provide all aspects of the child's care. It does not have to be just the parents. Few families can afford all the financial aspects of health care; therefore the need for financial planning is an important nursing intervention. This factor is important but not the most important.

The nurse is discussing toddler development with the mother of a 2 1/2-year-old child. Which statement by the mother indicates she has an understanding of how to help her daughter succeed in a developmental task while hospitalized? a. "I always help my daughter complete tasks to help her achieve a sense of accomplishment." b. "I provide many opportunities for my daughter to play with other children her age." c. "I consistently stress the difference between right and wrong to my daughter." d. "I encourage my daughter to do things for herself when she can."

ANS: D The toddler's developmental task is to achieve autonomy. Encouraging toddlers to do things for themselves assists with this developmental task (i.e., feeding self, putting on own socks). Toddlers should be encouraged to do what they can for themselves. Toddlers participate in parallel play. They play next to rather than with age mates. Excessive stress on the differences between right and wrong can stifle autonomy in the toddler and foster shame and doubt.

A 5-year-old girl's sibling has died from sudden infant death syndrome (SIDS). The parents are concerned because she showed more outward grief when her cat died than she is showing now. Based on the nurse's understanding of death in child development, how should the nurse explain this behavior to the parents? a. "This is suggestive of maladaptive coping and referral for counseling is needed." b. "The child is not old enough to have a concept of death." c. "The child is not old enough to have formed a significant attachment to her sibling." d. "The death may be so painful and threatening that the child is denying the death for now."

ANS: D This age child has limited defense mechanisms. Often, the child will react with more overt grief to a less significant loss than to the loss of a very significant person. Not showing outward grief is suggestive of limited defense mechanisms, not maladaptive coping. The child is beginning to understand the permanence of death. At age 5 years, this child will have formed a relationship with the infant sibling.