A school nurse is assessing a child who has a fever and notices several bite marks on the child's arm. The nurse should submit a referral for suspected child maltreatment based on which of the following additional findings? (Select all that apply.)

Child maltreatment encompasses both abuse and neglect, and a school nurse must recognize patterns that go beyond a single finding. Frequent school absences are a recognized indicator of neglect or abuse, as caregivers may keep children home to hide injuries or because basic needs such as stability are unmet. A child stating they are sick because they are bad reflects internalized shame and a distorted self-concept commonly seen in abused children who have been told their suffering is their own fault — this psychological indicator warrants serious concern. Wearing open-toed shoes in cold weather suggests the caregiver is failing to provide appropriate clothing, which constitutes physical neglect. Wrinkled and dirty clothes alone are a weaker indicator because many children have wrinkled clothing from normal play or laundry delays; while it can suggest neglect when combined with other signs, it is not independently compelling enough to be listed here. Coughing all day is a symptom of a respiratory illness, which explains the presenting fever and is not an indicator of maltreatment. Reporting suspected child abuse or neglect is a mandatory legal obligation for school nurses; they do not need to confirm abuse, only to have reasonable suspicion based on a pattern of findings. The combination of bite marks, frequent absences, shame-based self-blame, and weather-inappropriate clothing creates a pattern that warrants a referral.