While admitting a female client with bipolar disorder, the client begins to take off her clothes and throw them around the room. What action should the nurse take first?

• A. State it is unacceptable to undress during the interview
• B. Continue the interview and redirect attention
• C. Ask the client to undress in private
• D. Call security to remove clothing

Answer: (A)

When a patient with bipolar disorder exhibits disinhibited or sexualized behavior during an interview, the first move is to set a clear professional boundary. This helps protect the therapeutic relationship, ensures safety, and signals that certain behaviors are not acceptable in the clinical setting. A calm, direct statement like, “It’s not acceptable to undress during the interview. Please dress, and we can continue,” establishes that boundaries must be respected before further assessment can proceed.

This boundary-setting helps de-escalate the situation and keeps the focus on therapeutic goals. After the boundary is affirmed, the nurse can assess safety, determine whether the patient is able to continue the interview, and decide if additional support (such as staff presence or security) is needed if the behavior persists or escalates.