An admission assessment for a patient with bipolar disorder includes signs of boundary testing when the patient undresses during the interview. What is the most appropriate initial nursing action?

• A. State it is unacceptable to undress during the interview
• B. Ignore the behavior to avoid confrontation
• C. Continue the interview as if nothing happened
• D. Offer a blanket and ask the patient to cover up

Answer: (A)

Setting and maintaining professional boundaries is essential in psychiatric care. When a patient with mania tests limits by undressing during an interview, the first step is to establish a clear, nonjudgmental boundary and halt the behavior by saying that undressing is not allowed and the interview cannot continue until the patient is dressed. This immediate limit protects both patient and staff, reinforces professional conduct, and keeps the assessment on track. Ignoring the behavior, continuing as if nothing happened, or accommodating with a blanket does not address the boundary violation and can reinforce boundary testing, potentially compromising safety and the therapeutic relationship. Once the boundary is reestablished, you can resume the assessment within appropriate limits and address the patient's clinical needs.