I85PREP
⌘ K
NCSN study materials
NCSN study resources

NCSN practice questions

One question at a time. Build your NCSN understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Health Assessment and Screening

At what distance from the chart should a student stand when distance visual acuity is screened with a Snellen chart?

  1. 10 feet
  2. 20 feet Correct answer.
  3. 15 feet
  4. 40 feet

Explanation

The Snellen chart is calibrated so that the 20/20 line subtends the proper visual angle when the student stands 20 feet (6 meters) away. Screening at any other distance invalidates the recorded acuity.

Question 2Health Assessment and Screening

Which tool is used in school screening to detect red-green color vision deficiency?

  1. Stereopsis test
  2. Tumbling E chart
  3. Cover-uncover test
  4. Ishihara plates Correct answer.

Explanation

Ishihara plates present numbers or patterns embedded in dot fields that are invisible to people with red-green color vision deficiency. The other tools assess acuity, alignment, or depth perception.

Question 3Health Assessment and Screening

In which position is a student placed for the screening examination used to detect spinal curvature?

  1. Seated with the arms crossed and the chin tucked
  2. Prone with the head turned to one side
  3. Standing and bending forward at the waist Correct answer.
  4. Supine with the hips and knees flexed to 90 degrees and feet flat

Explanation

Scoliosis screening uses the forward bend (Adams) position, viewed from behind, so that asymmetric rib prominence or lumbar paraspinal elevation becomes visible. The arms hang freely and the knees remain straight.

Question 4Health Assessment and Screening

Where are nits most commonly found on a student infested with head lice?

  1. Only on the eyebrows and eyelashes
  2. Close to the scalp, at the nape and behind the ears Correct answer.
  3. Evenly distributed along the full length of the hair shaft
  4. In the skin folds of the axillae and groin

Explanation

Head lice deposit eggs within about 6 mm of the scalp, with the highest concentration at the nape of the neck and behind the ears. Finding nits at these sites supports the diagnosis of active infestation.

Question 5Health Assessment and Screening

Which set of frequencies is typically tested during pure-tone hearing screening in schools?

  1. 500, 1000, and 6000 Hz
  2. 1000, 2000, and 4000 Hz Correct answer.
  3. 250, 500, and 750 Hz
  4. 3000, 6000, and 8000 Hz

Explanation

School pure-tone screening conventionally tests 1000, 2000, and 4000 Hz because these frequencies cover the range most important for speech perception. Responses are usually required at a 20 dB hearing level.

Question 6Health Assessment and Screening

A BMI-for-age at or above which percentile is classified as obesity in children and adolescents?

  1. 90th percentile
  2. 99th percentile
  3. 85th percentile
  4. 95th percentile Correct answer.

Explanation

BMI-for-age from the 85th to below the 95th percentile is classified as overweight, while at or above the 95th percentile is classified as obesity. The 99th percentile is used as a severity marker rather than the threshold for obesity.

Question 7Health Assessment and Screening

Which specimen is used for the initial screening test for lead exposure in children?

  1. Urine
  2. Saliva
  3. Capillary blood Correct answer.
  4. Hair sample

Explanation

Capillary blood from a finger stick is the standard screening specimen for blood lead level in children. Results at or above the reference value are then confirmed with a venous sample.

Question 8Health Assessment and Screening

A student has a scaly, circular patch on the scalp with broken hairs and mild erythema. Which condition should the school nurse suspect?

  1. Alopecia areata
  2. Seborrheic dermatitis
  3. Scalp psoriasis
  4. Tinea capitis Correct answer.

Explanation

Patchy scaling with broken hairs and erythema is characteristic of tinea capitis, a dermatophyte infection of the scalp. It requires medical treatment and the student should be referred for evaluation.

Question 9Health Assessment and Screening

A 6-year-old reads 20/20 in the right eye but 20/40 in the left eye on repeat screening. What is the nurse's best action?

  1. Recommend the family purchase reading glasses
  2. Record the result as normal for a 6-year-old
  3. Refer for a comprehensive eye examination Correct answer.
  4. Rescreen the student in one year

Explanation

A two-line difference between eyes, or acuity worse than 20/30 at age 6, is a screening failure that warrants referral. Asymmetric acuity raises concern for amblyopia, which responds best to early treatment.

Question 10Health Assessment and Screening

A 10-year-old has blood pressure readings at or above the 95th percentile for age, sex, and height on three separate occasions. This finding is classified as:

  1. Elevated blood pressure requiring no referral
  2. Normal blood pressure for age
  3. Hypertension Correct answer.
  4. A single high reading that requires no action

Explanation

In children, blood pressure at or above the 95th percentile on three or more separate occasions establishes the diagnosis of hypertension. Persistent elevation requires medical evaluation rather than watchful waiting.

Question 11Health Assessment and Screening

Which validated tool is designed specifically to screen adolescents for substance use?

  1. C-SSRS
  2. PHQ-A
  3. AUDIT-C
  4. CRAFFT Correct answer.

Explanation

CRAFFT is a brief adolescent screening tool whose items address car use, relaxation, solitary use, forgetting, family or friend concern, and trouble. It is validated for use with adolescents in school and primary care settings.

Question 12Health Assessment and Screening

A 15-year-old scores in the moderate range on an adolescent depression screen. Which action is most appropriate for the school nurse?

  1. Reassure the student and file the result
  2. Repeat the questionnaire at the next annual physical
  3. Arrange follow-up and a suicide risk assessment Correct answer.
  4. Notify the parents only if the student agrees

Explanation

A moderate or higher score requires same-day follow-up, including direct assessment of suicidal ideation, and referral for further evaluation. Safety takes precedence over a student's preference for confidentiality.

Question 13Health Assessment and Screening

A student reports headache, dizziness, and difficulty concentrating after striking the head in gym class. The nurse should first:

  1. Send the student back to class and monitor for 24 hours
  2. Remove the student from play and refer for evaluation Correct answer.
  3. Apply ice to the head and clear the student for practice
  4. Allow return to play if symptoms clear within 15 minutes

Explanation

Suspected concussion requires immediate removal from activity and evaluation by a qualified provider before any return to play. Symptoms may evolve, so same-day clearance on the field is never appropriate.

Question 14Health Assessment and Screening

An 11-year-old has new-onset nocturnal enuresis, frequent thirst, and a 5-pound weight loss over several weeks. Which condition should the nurse suspect?

  1. Type 1 diabetes mellitus Correct answer.
  2. Diabetes insipidus
  3. Iron-deficiency anemia
  4. Urinary tract infection

Explanation

The triad of polyuria, polydipsia, and weight loss in a school-age child is the classic presentation of new-onset type 1 diabetes. The nurse should arrange urgent medical evaluation for glucose testing.

Question 15Health Assessment and Screening

A student with varicella may return to school when:

  1. Antiviral therapy has been given for 3 days
  2. All lesions have crusted over Correct answer.
  3. Fever has been absent for 12 hours
  4. The rash has begun to fade

Explanation

Varicella is communicable until all lesions have formed crusts, which typically takes about 5 to 7 days after rash onset. Exclusion until crusting protects susceptible students and staff.

Question 16Health Assessment and Screening

Exclusion from school for a student with impetigo is recommended until:

  1. The lesions are no longer itchy or draining
  2. A follow-up culture is confirmed negative
  3. All lesions are completely healed and no new lesions have appeared
  4. At least 24 hours of antibiotic therapy has been completed Correct answer.

Explanation

Impetigo is no longer considered contagious after approximately 24 hours of appropriate antibiotic therapy. Healing and follow-up cultures are not required before the student returns.

Question 17Health Assessment and Screening

A flat (type B) tympanogram in a student most likely indicates:

  1. Sensorineural hearing loss
  2. Middle ear effusion Correct answer.
  3. Normal middle ear function
  4. Impacted cerumen alone

Explanation

A type B tympanogram shows no tympanic membrane mobility, which is consistent with fluid in the middle ear, perforation, or probe occlusion. The student should be referred for medical evaluation of possible effusion.

Question 18Health Assessment and Screening

Which history finding places a student at highest risk for hearing loss and warrants priority screening?

  1. Seasonal allergic rhinitis each spring
  2. Two episodes of acute otitis media treated at age 3
  3. A 6-week NICU stay with mechanical ventilation Correct answer.
  4. Grandparents with age-related hearing loss

Explanation

Prolonged NICU care with mechanical ventilation is a recognized risk factor for sensorineural hearing loss. Such students require careful and early audiologic monitoring regardless of screening results.

Question 19Health Assessment and Screening

A 4-year-old's weight has fallen from the 50th to the 10th percentile over 6 months. What should the nurse do first?

  1. Refer the family to a nutritionist without further evaluation
  2. Document the change as normal growth variation
  3. Notify the parent and arrange medical follow-up Correct answer.
  4. Recheck the weight at the next annual screening

Explanation

Crossing two major weight percentiles downward suggests faltering growth and requires prompt medical evaluation. The nurse notifies the family and facilitates referral rather than waiting or substituting nutrition counseling for diagnosis.

Question 20Health Assessment and Screening

A student develops hives, wheezing, and lip swelling minutes after eating a snack containing peanut. What is the nurse's first action?

  1. Call the parent to obtain consent before treating
  2. Give an oral antihistamine and observe for 10 minutes
  3. Have the student sit upright and sip water
  4. Give epinephrine per the emergency care plan Correct answer.

Explanation

Airway involvement with hives and wheezing after a known exposure indicates anaphylaxis, and epinephrine is the first-line treatment. It should be given promptly according to the student's individualized plan before other measures.

Question 21Health Assessment and Screening

A nurse using a scoliometer records an angle of trunk rotation of 7 degrees. What is the appropriate action?

  1. Refer the student for further evaluation Correct answer.
  2. Recommend stretching and reassess in 6 months
  3. Record the finding as within normal limits
  4. Rescreen the student in 12 months

Explanation

An angle of trunk rotation of about 7 degrees or more is the accepted threshold for referral for imaging and orthopedic evaluation. Smaller readings are typically rescreened rather than referred.

Question 22Health Assessment and Screening

A child's capillary blood lead screening result is 6 micrograms per deciliter. What is the next step?

  1. Begin chelation therapy immediately
  2. Obtain a venous blood lead level to confirm the result Correct answer.
  3. Repeat the capillary test in 12 months
  4. Take no action, because the value is below the reference value

Explanation

Capillary specimens are prone to contamination from the skin surface, so any result at or above the reference value must be confirmed with a venous sample. Treatment decisions are based on the confirmed venous level.

Question 23Health Assessment and Screening

A 12-year-old has systolic pressure at the 99th percentile plus 8 mmHg on three separate visits. How is this classified?

  1. Elevated blood pressure
  2. White coat hypertension
  3. Stage 1 hypertension
  4. Stage 2 hypertension Correct answer.

Explanation

In pediatric staging, stage 1 hypertension ranges from the 95th percentile to the 99th percentile plus 5 mmHg, while stage 2 begins at the 99th percentile plus 5 mmHg. A reading at the 99th percentile plus 8 mmHg therefore meets stage 2 criteria.

Question 24Health Assessment and Screening

During screening, a student responds at 1000 and 2000 Hz but not at 4000 Hz at 20 dB in the right ear. What should the nurse do?

  1. Refer only if the left ear also fails screening
  2. Refer the student for a full audiological evaluation Correct answer.
  3. Rescreen the same ear next week and pass it if unchanged
  4. Pass the student because two of three frequencies were heard

Explanation

Failure to respond at any screening frequency in either ear constitutes a failed screen and requires referral for audiologic evaluation. Missing a high frequency can signal noise-induced or early sensorineural loss that should not be ignored.

Question 25Health Assessment and Screening

A student's immunization record shows a second dose given 2 weeks after the first, although the minimum interval is 4 weeks. What should the nurse do?

  1. Count the doses because the student is older than 7 years
  2. Accept both doses because both were administered
  3. Accept the doses if a parent signs a written statement
  4. Invalidate the second dose and refer for revaccination Correct answer.

Explanation

Doses given before the minimum interval has elapsed do not count as valid and must be repeated. Age or parental attestation cannot convert an invalidly spaced dose into a valid one.

Question 26Health Assessment and Screening

Which screening technique detects strabismus by comparing the position of the corneal light reflex in each eye?

  1. Hirschberg test Correct answer.
  2. Snellen visual acuity test
  3. Confrontation visual field test
  4. Cover-uncover test

Explanation

The Hirschberg test shines a light into the eyes and compares the reflection on each cornea; an asymmetric reflex suggests ocular misalignment. It is a quick screening method for strabismus in children.

Question 27Health Assessment and Screening

A school nurse uses a blood pressure cuff that is too small for a student's arm. How will this affect the reading?

  1. It will falsely raise the blood pressure reading. Correct answer.
  2. It will have no effect on the reading.
  3. It will widen the pulse pressure only.
  4. It will falsely lower the systolic reading.

Explanation

A cuff bladder should encircle most of the arm and cover about two-thirds of its length. A cuff that is too small compresses the artery over a smaller area, so a higher pressure is needed to occlude it, producing a falsely elevated reading.

Question 28Health Assessment and Screening

A 6-year-old whose mother has active pulmonary tuberculosis has a tuberculin skin test with 6 mm of induration at 48 hours. How should the nurse interpret this result?

  1. Equivocal, requiring a repeat test in 3 months
  2. Negative, because induration is less than 10 mm
  3. Positive, because the child is a close contact Correct answer.
  4. Invalid, because the test was read too early

Explanation

For children who are close contacts of a person with infectious tuberculosis, HIV-infected, or immunosuppressed, an induration of 5 mm or greater is considered positive. This child's 6 mm result therefore indicates tuberculosis infection and requires further evaluation.

Question 29Health Assessment and Screening

At a 12-month well-child visit, a capillary hemoglobin result is 10.6 g/dL. What is the nurse's best next action?

  1. Refer the infant for an immediate blood transfusion
  2. Repeat the measurement with a venous sample Correct answer.
  3. Begin a high-iron diet and recheck in 1 year
  4. Document the result as normal for age

Explanation

At 12 months, hemoglobin below 11.0 g/dL is considered low and warrants follow-up. Capillary specimens are prone to dilution and false elevation or depression, so an abnormal result should be confirmed with a venous sample before management decisions are made.

Question 30Health Assessment and Screening

A 14-year-old has a BMI at the 87th percentile, a family history of type 2 diabetes, and acanthosis nigricans on the neck. Which screening test is indicated?

  1. Random urine glucose dipstick
  2. Fasting plasma glucose or hemoglobin A1c Correct answer.
  3. Oral glucose tolerance test only if symptoms occur
  4. Serum insulin level

Explanation

Youth with a BMI at or above the 85th percentile plus risk factors such as family history or acanthosis nigricans should be screened for type 2 diabetes starting at age 10 or puberty. Fasting plasma glucose or hemoglobin A1c is the recommended screening approach.

Question 31Health Promotion and Disease Prevention

A school nurse is teaching a fourth-grade class about hand hygiene. What is the minimum recommended time for washing hands with soap and water?

  1. 10 seconds
  2. 20 seconds Correct answer.
  3. 5 seconds
  4. 60 seconds

Explanation

Guidelines recommend scrubbing all hand surfaces with soap and water for at least 20 seconds, roughly the time it takes to hum the birthday song twice. Alcohol-based sanitizer with at least 60% alcohol may be used when hands are not visibly soiled.

Question 32Health Promotion and Disease Prevention

A school nurse is screening a kindergarten student for distance visual acuity. Which tool is appropriate for this screening?

  1. Adams forward bend test
  2. Tympanometry
  3. Snellen eye chart Correct answer.
  4. Pure-tone audiometry

Explanation

Distance visual acuity is screened with a Snellen or similar acuity chart, matched to the child's age and ability to identify letters, symbols, or pictures. A referral is indicated when acuity falls below the program's pass criteria or when the two eyes differ significantly.

Question 33Health Promotion and Disease Prevention

Head lice infestations among school-age children are spread most commonly through which route?

  1. Coughing droplets
  2. Sharing combs or hats
  3. Head-to-head contact Correct answer.
  4. Contact with pets

Explanation

Head lice are wingless insects that move by crawling, and the vast majority of transmission occurs with direct head-to-head contact during play, sleepovers, and similar activities. Fomite transmission is uncommon, and lice do not survive on pets or spread through airborne droplets.

Question 34Health Promotion and Disease Prevention

A school nurse is advising staff before an outdoor field day. To provide adequate sun protection, sunscreen should be reapplied at which interval?

  1. Every 8 hours
  2. At least every 2 hours Correct answer.
  3. Once in the morning only
  4. Every 15 minutes

Explanation

Sunscreen should be applied before sun exposure and reapplied at least every two hours, and more often after swimming or heavy sweating. Reapplication matters because sunscreen breaks down and rubs off over time regardless of the labeled SPF.

Question 35Health Promotion and Disease Prevention

The national physical activity guideline for children and adolescents aged 6 to 17 years calls for how much moderate-to-vigorous activity each day?

  1. 30 minutes
  2. 15 minutes
  3. 60 minutes Correct answer.
  4. 120 minutes

Explanation

Children and adolescents should accumulate at least 60 minutes of moderate-to-vigorous physical activity daily, including vigorous activity and muscle- and bone-strengthening activities on several days each week. Schools support this through recess, physical education, and active classroom breaks.

Question 36Health Promotion and Disease Prevention

School-based body mass index (BMI) screening programs are primarily intended to accomplish which goal?

  1. Flag students for follow-up Correct answer.
  2. Diagnose pediatric obesity
  3. Determine IEP eligibility
  4. Replace annual well-child visits

Explanation

BMI is a screening measure, not a diagnosis; its purpose is to identify students whose growth pattern warrants further evaluation by a health care provider. Screening results are communicated confidentially to families along with resources, and they never substitute for a comprehensive clinical assessment.

Question 37Health Promotion and Disease Prevention

Which situation best describes bullying as defined in school health and safety policy?

  1. A single disagreement between friends
  2. Teasing that both students find funny
  3. Repeated harm with a power imbalance Correct answer.
  4. Accidental injury during physical education class

Explanation

Bullying is unwanted, repeated aggressive behavior that involves a real or perceived power imbalance and causes harm. A one-time conflict, an accident, or mutually enjoyed joking does not meet that definition, though all such incidents may still require staff follow-up.

Question 38Health Promotion and Disease Prevention

Which vaccine is routinely recommended for all adolescents at 11 to 12 years of age, with a booster dose at 16 years?

  1. Hepatitis B
  2. Varicella
  3. Meningococcal ACWY Correct answer.
  4. Inactivated poliovirus

Explanation

The meningococcal conjugate (MenACWY) vaccine is given at 11 to 12 years with a booster at 16 years to maintain protection through the peak-risk late adolescent years. Meningococcal B vaccine is a separate product recommended for adolescents based on shared clinical decision-making or increased risk.

Question 39Health Promotion and Disease Prevention

Which screening maneuver is used to detect possible adolescent idiopathic scoliosis?

  1. Babinski reflex
  2. Adams forward bend test Correct answer.
  3. Romberg balance test
  4. Barlow provocative maneuver

Explanation

With the Adams forward bend test, the student bends forward at the waist while the screener looks for thoracic or lumbar asymmetry, such as a rib hump or unequal shoulder height. A positive finding warrants referral for clinical evaluation and possible imaging.

Question 40Health Promotion and Disease Prevention

Which statement about influenza vaccination for school-age children is accurate?

  1. Required only for students with chronic respiratory disease
  2. Given once, then boosted every ten years
  3. Recommended yearly from age 6 months onward Correct answer.
  4. Contraindicated in any child with egg allergy

Explanation

Annual influenza vaccination is recommended for everyone 6 months of age and older, with the dose repeated each season because circulating strains change and immunity wanes. Most children with egg allergy can be vaccinated in a routine setting under current guidance.

Question 41Health Promotion and Disease Prevention

The human papillomavirus (HPV) vaccine series is routinely recommended to begin at which age?

  1. 11 to 12 years Correct answer.
  2. 2 to 4 years
  3. 4 to 6 years
  4. 16 to 18 years

Explanation

Routine HPV vaccination is recommended at 11 to 12 years, though the series may begin as early as 9 years. Two doses are needed when the series starts before age 15, and three doses when it starts at 15 years or older.

Question 42Health Promotion and Disease Prevention

An asthma action plan uses green, yellow, and red zones. A student in the yellow zone typically has which findings?

  1. No symptoms and peak flow at 80 percent of best or higher
  2. Severe distress and peak flow below 50 percent of best
  3. Cough or wheeze with peak flow at 50 to 79 percent of best Correct answer.
  4. Symptoms only with exercise and a normal peak flow

Explanation

The yellow zone signals caution: the student has mild-to-moderate symptoms such as cough, wheeze, or chest tightness and a peak flow between 50 and 79 percent of personal best. The plan then directs quick-relief medication, parent notification, and reassessment.

Question 43Health Promotion and Disease Prevention

A student with a known food allergy develops hives, wheezing, and difficulty breathing after lunch. What should the school nurse do first?

  1. Call 911 and wait for emergency medical services
  2. Give an oral antihistamine and observe
  3. Send the student to the health office to lie down
  4. Give epinephrine, then call 911 Correct answer.

Explanation

Epinephrine is the first-line treatment for anaphylaxis and should be given intramuscularly without delay, followed by activation of emergency medical services. Antihistamines do not reverse airway or cardiovascular compromise and are only an adjunct.

Question 44Health Promotion and Disease Prevention

A student with type 1 diabetes is shaky, sweaty, and confused but is alert and able to swallow. What is the appropriate first action?

  1. Give 15 grams of fast-acting carbohydrate Correct answer.
  2. Give a dose of glucagon by injection
  3. Withhold all food and call the parents
  4. Administer the student's rapid-acting insulin

Explanation

These signs indicate hypoglycemia, which is treated with 15 grams of fast-acting carbohydrate, followed by a recheck in about 15 minutes and a repeat dose if the glucose remains low. Glucagon is reserved for students who cannot swallow or who are unresponsive.

Question 45Health Promotion and Disease Prevention

A student begins having a generalized tonic-clonic seizure in the cafeteria. Which action should the school nurse take?

  1. Place a tongue blade between the teeth
  2. Restrain the limbs to limit movement
  3. Cushion the head and turn to the side Correct answer.
  4. Give oral fluids once the shaking stops

Explanation

During a seizure the nurse protects the student from injury by cushioning the head, clearing nearby objects, and positioning the student on the side to maintain the airway. Timing the seizure and calling emergency services for prolonged or repeated seizures is also part of the response.

Question 46Health Promotion and Disease Prevention

Pure-tone hearing screening in schools typically tests which set of frequencies?

  1. 500 and 1000 Hz only
  2. 250, 500, and 750 Hz
  3. 1000, 2000, and 4000 Hz Correct answer.
  4. 2000 and 8000 Hz only

Explanation

School hearing screening commonly presents tones at 1000, 2000, and 4000 Hz at a screening level of about 20 dB, because these frequencies are most important for hearing speech. Some programs also include 500 Hz to improve detection of low-frequency loss.

Question 47Health Promotion and Disease Prevention

A school nurse teaches a parent to use a metered-dose inhaler with a spacer. Which strategy best confirms that the teaching was effective?

  1. Ask the parent whether the instructions made sense
  2. Ask the parent to sign a form acknowledging instruction
  3. Ask the parent to demonstrate the technique back Correct answer.
  4. Give the parent a printed handout about asthma

Explanation

Teach-back requires the learner to demonstrate or restate the skill in their own words, which reveals actual understanding rather than presumed understanding. A signed form, a handout, or a yes/no question does not confirm that the parent can perform the technique correctly.

Question 48Health Promotion and Disease Prevention

Dental sealants provide the greatest benefit when applied to which tooth surfaces?

  1. Adolescent third molars
  2. Erupting primary incisors
  3. Permanent molar chewing surfaces Correct answer.
  4. Anterior teeth with smooth surfaces

Explanation

Sealants are placed in the pits and fissures of permanent molars, and sometimes premolars, shortly after eruption, when those surfaces are most vulnerable to decay. Smooth surfaces are less retentive for plaque and benefit far less from sealing.

Question 49Health Promotion and Disease Prevention

A high school nurse is planning a prevention program about e-cigarette use. Which approach is best supported by evidence?

  1. Showing graphic images of lung disease only
  2. Building refusal skills and correcting norms Correct answer.
  3. Inviting a former user to describe flavors
  4. Requiring students to sign a no-vaping pledge

Explanation

Effective prevention combines social resistance skills training with correction of the misperception that most peers vape, along with accurate information about nicotine and other risks. Fear-based single-component messaging and pledges alone have limited effect on behavior.

Question 50Health Promotion and Disease Prevention

A parent requests a nonmedical exemption from a required school immunization. Under most state laws, which statement is accurate?

  1. It must follow the state's documentation rules Correct answer.
  2. The school nurse may grant it without paperwork
  3. Federal law requires schools to accept all exemptions
  4. The student is permanently excluded from school

Explanation

School immunization requirements and exemption procedures are established by state law, so the acceptable exemption types, forms, and deadlines vary by state and must be followed precisely. Students with exemptions may also be excluded temporarily during an outbreak of a vaccine-preventable disease.