After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

A. The Kernig sign is a clinical test used to diagnose meningitis, not stroke. It involves flexing the patient’s hip and knee and then attempting to extend the knee while the hip is flexed. Pain or resistance during this maneuver can suggest meningeal irritation.
B. Arm weakness refers to the loss of strength or control in one or both arms, which can be a sign of a stroke. It may be noticeable when a person is unable to lift their arm or keep it raised.
C. Sudden confusion, trouble understanding, or difficulty speaking can be signs of a stroke. This may involve problems with language or comprehension, which are related to the areas of the brain responsible for these functions.
D. Face drooping, especially on one side of the face, is a classic sign of stroke. It occurs when the muscles on one side of the face weaken or become paralyzed.
E. The Babinski reflex is a test where the sole of the foot is stroked, and the normal response in adults is the downward flexion of the toes. An abnormal Babinski reflex (upward extension of the big toe) can indicate neurological problems but is not a specific warning sign of stroke.
F. Speech difficulty, such as slurred speech or trouble finding words, is a common sign of a stroke. It can involve problems with articulation, coherence, or understanding language.

A. A hallucination is a sensory experience that occurs without any external stimulus. It involves perceiving things that are not present in the environment, such as hearing voices or seeing things that are not there. The young man hearing his deceased sister talking to him in his head is an example of an auditory hallucination, which is a common symptom in schizophrenia.
B. Perseveration is the repetitive and persistent repetition of a particular response, such as a word or action, despite the absence of a stimulus or the problem being resolved. It is not related to abnormal sensory perceptions but rather to repetitive behaviors or speech. The young man's experience of hearing voices does not fit this description.
C. A fugue state is a type of dissociative disorder where a person suddenly and unexpectedly travels away from home or customary work locations and cannot recall their past. It often involves amnesia for personal history. The scenario described does not involve such travel or amnesia but rather auditory experiences, making this term irrelevant.
D. An illusion is a misperception of an actual external stimulus. It involves incorrectly interpreting a real sensory input, such as mistaking a shadow for a person. Since the young man is not misinterpreting a real external stimulus but rather hearing something that is not present at all, an illusion does not accurately describe his experience.