The nurse assessing a client prescribed a muscle relaxant should document which of the following as part of the initial assessment?

• A. Blood pressure and pulse
• B. Respiratory rate
• C. Awareness of muscle function, pain, and range of motion
• D. Skin turgor

Answer: (C)

Baseline neuromuscular status is what matters most when assessing a patient starting a muscle relaxant. These meds directly affect skeletal muscle function, so the initial documentation should capture how well the patient can move, what their muscle strength is, and any pain or stiffness they’re experiencing. Recording awareness of muscle function, pain, and range of motion gives a clear baseline to compare against future assessments, helping you judge whether the drug is decreasing muscle spasm as intended and whether any adverse effects like excessive weakness or reduced coordination are occurring. While vital signs such as blood pressure, pulse, and respirations are important for overall safety, they don’t directly reflect the drug’s effect on the musculoskeletal system. Skin turgor isn’t relevant to muscle relaxant effects.