The school nurse is preparing a presentation for elementary school teachers to inform them when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? Select all that apply.

Rationale: A. Shaking that changes the child's handwriting legibility: Sudden onset of tremors affecting fine motor skills may indicate a neurological issue, such as a seizure disorder or early signs of a neurological condition, and requires prompt evaluation by the school nurse. B. Bruises on both knees after the weekend: Bruises on the knees in children are often consistent with normal play and activity. Unless the bruises are unusual in pattern or location (e.g., upper arms, back), they typically do not require immediate referral. C. Sunburn with blisters on the face, arms, and hands: Blistering sunburns can lead to dehydration, pain, and secondary infection. Facial involvement and blistering elevate the severity and warrant assessment and possible treatment recommendations. D. Refuses to complete written homework assignments: While this behavior might suggest learning or behavioral challenges, it is not an urgent health issue requiring immediate referral. Teachers should monitor and possibly refer through academic support services, not directly to the nurse. E. Thirst and frequent requests for bathroom breaks: These symptoms could be early signs of undiagnosed diabetes mellitus and warrant immediate attention from the school nurse to initiate further assessment and notify the child’s guardian.