While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Rationale: A. Change to less anxiety-promoting questions: Adjusting questioning techniques may be helpful later, but it does not address the immediate concern of inappropriate behavior. The nurse must first set clear boundaries to maintain safety and therapeutic structure. B. Ignore the client's inappropriate behavior: Ignoring such behavior may allow it to escalate or reinforce it as acceptable. Clients with mania often test boundaries, so ignoring may compromise safety and therapeutic rapport. C. Leave the client's room so she can act out her anxiety: Leaving the client alone while she is disinhibited and potentially unsafe is inappropriate. The nurse has a responsibility to redirect behavior and ensure a safe environment. D. State it is unacceptable to undress during the interview: Clearly and calmly setting limits is the most appropriate first action. It helps maintain dignity, ensures safety, and models acceptable behavior in a therapeutic manner during a manic episode.