32 terms

Nclex Review: Joint Replacement Surgery, Amputation

In preparation for total knee surgery, a 200-lb client with osteoarthritis must lose weight. Which of the following exercises should the nurse recommend as best if the client has no contraindications?
1. Weight lifting.
2. Walking.
3. Aquatic exercise.
4. Tai chi exercise.
When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.
Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time?
1. Teaching how to prevent hip flexion.
2. Demonstrating coughing and deep-breathing techniques.
3. Showing the client what an actual hip prosthesis looks like.
4. Assessing the client's fears about the procedure.
Before implementing a teaching plan, the nurse should determine the client's fears about the procedure. Only then can the client begin to hear what the nurse has to share about the individualized teaching plan designed to meet the client's needs. In the preoperative period, the client needs to learn how to correctly prevent hip flexion and to demonstrate coughing and deep breathing. However, this teaching can be effective only after the client's fears have been assessed and addressed. Although the client may appreciate seeing what a hip prosthesis looks like, so as to understand the new body part, this is not a necessity.
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage? 1. Numbness.
2. Bleeding.
3. Dislocation.
4. Pinkness.
The nurse should suspect nerve damage if numbness is present. However, whether the damage is short-term and related to edema or long-term and related to permanent nerve damage would not be clear at this point. The nurse needs to continue to assess the client's neurovascular status, including pain, pallor, pulselessness, paresthesia, and paralysis (the five P's). Bleeding would suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would suggest adequate circulation to the area. Numbness would suggest neurologic damage.
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
1. A developing infection.
2. Bleeding in the operative site.
3. Joint dislocation.
4. Glue seepage into soft tissue.
The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form before the wound is closed.
A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?
1. The client drinks 2,000 mL of fluid per day.
2. The client understands how to manage the incision.
3. The client's bed linens are changed as needed.
4. The client's skin remains cool throughout hospitalization.
An average adult requires approximately 1,100- 1,400 mL of fluids per day. In some instances, such as when a person has an increase in body temperature or has increased perspiration, additional water may be necessary. With an increase in body temperature, there is also an increase in insensible fluid loss. The increased loss of fluid causes an increased need for fluid replacement. If the loss is significant and/ or goes untreated, an individual's intake will not be balanced with output. Managing the incision, changing the bed linens, or keeping the client's skin cool are not outcomes indicative of resolution of a fluid volume deficit.
After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following?
1. Elevate the sequential compression device (SCD) on two pillows.
2. Change the settings on the SCD to make the client more comfortable.
3. Stop the SCD to remove dressings and bathe the leg.
4. Discontinue the SCD when the client is ambulatory.
After knee arthroplasty, the knee will be extended and immobilized with a firm compression dressing and an adjustable soft extension splint in place. A sequential compression device (SCD) will be applied. The SCD can be discontinued when the client is ambulatory, but while the client is in bed the SCD needs to be maintained to prevent thromboembolism. The SCD should be positioned on the bed, but not on two pillows. Settings for the SCD are ordered by the orthopedic surgeon. Initial dressing changes are completed by the orthopedic surgeon and changed as needed per physician order.
The nurse is preparing the discharge of a client who has had a knee replacement with a metal joint. The nurse should instruct the client about which of the following? Select all that apply.
1. Notify health care providers about the joint prior to invasive procedures.
2. Avoid use of Magnetic Resonance Imaging (MRI) scans. 3. Notify airport security that the joint may set off alarms on metal detectors.
4. Refrain from carrying items weighing more than 5 lb.
5. Limit fluid intake to 1,000 mL/ day.
1, 2, 3.
The nurse should instruct the client to notify the dentist and other health care providers of the need to take prophylactic antibiotics if undergoing any procedure (e.g., tooth extraction) due to the potential of bacteremia. The nurse should also advise the client that the metal components of the joint may set off the metal-detector alarms in airports. The client should also avoid MRI studies because the implanted metal components will be pulled toward the large magnet core of the MRI. Any weight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to 5 lb. Post surgery, the client can resume a normal diet with regular fluid intake.
Following a total hip replacement, the nurse should position the client in which of the following ways?
1. Place weights alongside of the affected extremity to keep the extremity from rotating.
2. Elevate both feet on two pillows.
3. Keep the lower extremities adducted by use of an immobilization binder around both legs.
4. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.
After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction. The client must not abduct or flex the operated hip because this may produce dislocation.
Following a total hip replacement, the nurse should do which of the following? Select all that apply.
1. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours.
2. Encourage the client to use the overhead trapeze to assist with position changes.
3. For meals, elevate the head of the bed to 90 degrees. 4. Use a fracture bedpan when needed by the client.
5. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises.
2, 4, 5.
Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.
A client is to have a total hip replacement. The preoperative plan should include which of the following? Select all that apply.
1. Administer antibiotics as prescribed to ensure therapeutic blood levels.
2. Apply leg compression device.
3. Request a trapeze be added to the bed.
4. Teach isometric exercises of quadriceps and gluteal muscles.
5. Demonstrate crutch walking with a 3-point gait.
6. Place Buck's traction on the bed.
1, 3, 4.
Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck's traction. The client will require anti-embolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per physician order.
The nurse is teaching the client to administer enoxaparin (Lovenox) following a total hip arthroplasty? The nurse should instruct the client about which of the following? Select all that apply.
1. Report promptly any difficulty breathing, rash, or itching. 2. Notify the health care provider of unusual bruising.
3. Avoid all aspirin-containing medications.
4. Wear or carry medical identification. 5. Expel the air bubble from the syringe before the injection. 6. Remove needle immediately after medication is injected.
1, 2, 3, 4.
Client/ family teaching should include advising the client to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to healthcare provider immediately. Instruct the client not to take aspirin or nonsteroidal anti-inflammatory drugs without consulting health care provider while on therapy. A low-molecular weight heparin is considered to be a high-risk medication and the client should wear or carry medical identification. The air bubble should not be expelled from the syringe because the bubble insures the client receives the full dose of the medication. The client should allow 5 seconds to pass before withdrawing the needle to prevent seepage of the medication out of the site.
A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying which of the following?
1. "Don't worry. Your new hip is very strong."
2. "Use of a cushioned toilet seat helps to prevent dislocation."
3. "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them."
4. "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation."
Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.
The nurse is assessing a client who had a left hip replacement 36 hours ago. Which of the following indicates the prosthesis is dislocated? Select all that apply.
1. The client reported a "popping" sensation in the hip.
2. The left leg is shorter than the right leg.
3. The client has sharp pain in the groin.
4. The client cannot move his right leg.
5. The client
1, 2, 3.
Dislocation of a hip prosthesis may occur with positioning that exceeds the limits of the prosthesis. The nurse must recognize dislocation of the prosthesis. Signs of prosthesis dislocation include: acute groin pain in the affected hip, shortening of the affected leg, restricted ability or inability to move the affected leg, and reported "popping" sensation in the hip. Toe wiggling is not a test for potential hip dislocation.
A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
1. Stabilize the leg with Buck's traction.
2. Apply an ice pack to the affected hip.
3. Position the client toward the opposite side of the hip.
4. Notify the orthopedic surgeon.
If a prosthesis becomes dislocated, the nurse should immediately notify the surgeon. This is done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintain circulation. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. If ordered by the surgeon, an ice pack may be applied post reduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may order the client be turned toward the side of the reduced hip but that is not the nurse's first response.
The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first? 1. A 55-year-old client who is 6 feet tall and weighs 180 lb. 2. A 90-year-old who lives alone.
3. A 74-year-old who has periodontal disease with periodontitis.
4. A 75-year-old who has asthma and uses an inhaler.
Infection is a serious complication of total hip replacement and may necessitate removal of the implant. Clients who are obese, poorly nourished, elderly, have poorly controlled diabetes, rheumatoid arthritis, or concurrent infections (e.g., dental, urinary tract) are at high risk for infection. Clients who are of normal weight and have well-controlled chronic diseases are not at risk for infection. Living alone is not a risk factor for infection.
The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit?
1. The client can walk throughout the entire hospital with a walker.
2. The client can walk the length of a hospital hallway with minimal pain.
3. The client has increased independence in transfers from bed to chair.
4. The client can raise the affected leg 6 inches with assistance.
Expected outcomes at the time of discharge from the surgical unit after a hip replacement include the following: increased independence in transfers, participates in progressive ambulation without pain or assistance, and raises the affected leg without assistance. The client will not be able to walk throughout the hospital, walk for a distance without some postoperative pain, or raise the affected leg more than several inches. The client may be referred to a rehabilitation unit in order to achieve the additional independence, strength, and pain relief.
The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply.
1. Reduced edema of the left knee.
2. Skin warm to touch.
3. Capillary refill response.
4. Moves toes.
5. Pain absent.
6. Pulse on left leg weaker than right leg.
1, 2, 3, 4.
Postoperatively, the knee in a total knee replacement is dressed with a compression bandage and ice may be applied to control edema and bleeding. Recurrent assessment by the nurse for neurovascular changes can prevent loss of limb. Normal neurovascular findings include: color normal, extremity warm, capillary refill less than 3 seconds, moderate edema, tissue not palpably tense, pain controllable, normal sensations, no paresthesia, normal motor abilities, no paresis or paralysis, and pulses strong and equal.
On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following?
1. Encourage the client to apply full weight-bearing.
2. Order a walker for the client.
3. Place a straight-backed chair at the foot of the bed.
4. Apply a knee immobilizer.
The knee is usually protected with a knee immobilizer (splint, cast, or brace) and is elevated when the client sits in a chair. Pre- and post-surgery, the physician prescribes weight-bearing limits and use of assistive devices for progressive ambulation. Positioning a straight-backed chair at the foot of the bed is not an action conducive for getting the client out of bed on the evening of surgery for a total knee replacement.
When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information in the discharge plan? Select all that apply.
1. Report signs of infection to health care provider.
2. Keep the affected leg and foot on the floor when sitting in a chair.
3. Remove anti-embolism stockings when sleeping.
4. The physical therapist will encourage progressive ambulation with use of assistive devices.
5. Change the dressing daily.
1, 4.
After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. After discharge, the client may undergo physical therapy on an outpatient basis per physician order. The client should leave the dressing in place until the follow-up visit with the surgeon.
Following a total joint replacement, which of the following complications has the greatest likelihood of occurring?
1. Deep vein thrombosis (DVT).
2. Polyuria.
3. Intussception of the bowel.
4. Wound evisceration.
Deep vein thrombosis is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a DVT or PE are at high risk. Immobility produces venous stasis, increasing the client's chance to develop a venous thromboembolism. Signs of a DVT include: unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the physician for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Intussusception of the bowel and wound evisceration tend to occur after abdominal surgeries.
Which of the following should the nurse identify as the least likely factor contributing to a client's peripheral vascular disease?
1. Uncontrolled diabetes mellitus for 15 years.
2. A 20-pack-year history of cigarette smoking.
3. Current age of 39 years.
4. A serum cholesterol concentration of 275 mg/ dL.
Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease. Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because of the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/ dL are considered a risk factor for peripheral vascular disease.
A client has severe arterial occlusive disease and gangrene of the left great toe. Which of the following findings is expected?
1. Edema around the ankle.
2. Loss of hair on the lower leg.
3. Thin, soft toenails.
4. Warmth in the foot.
The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.
A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should:
1. Have the client sign a consent form for the procedure.
2. Administer a pretest sedative as appropriate.
3. Keep the client tobacco-free for 30 minutes before the test.
4. Wrap the client's affected foot with a blanket.
The client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arteries. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive an opioid analgesic, not a sedative, to control the pain as the blood pressure cuffs are inflated during the Doppler studies to determine the ankle-to-brachial pressure index. The client's ankle should not be covered with a blanket because the weight of the blanket on the ischemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet off the affected foot.
The client with peripheral arterial disease says, "I've really tried to manage my condition well." Which of the following should the nurse determine as appropriate for this client? 1. Resting with the legs elevated above the level of the heart.
2. Walking slowly but steadily for 30 minutes twice a day.
3. Minimizing activity as much and as often as possible.
4. Wearing antiembolism stockings at all times when out of bed.
Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.
Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively?
1. Daily lubrication of the feet.
2. Soaking the feet in warm water.
3. Applying antiembolism stockings.
4. Wearing firm, supportive leather shoes.
Daily lubrication, inspection, cleaning, and patting dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the feet in warm water should be avoided because soaking can lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insufficiency typically experiences sensory changes, so the client may be unable to detect water that is too warm, thus placing the client at risk for burns. Antiembolism stockings, appropriate for clients with venous insufficiency, are inappropriate for clients with arterial insufficiency and could lead to a worsening of the condition. Footwear should be roomy, soft, and protective and allow air to circulate. Therefore, firm, supportive leather shoes would be inappropriate.
A client says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be the nurse's most therapeutic response?
1. "At least you will still have one good leg to use."
2. "Tell me more about how you're feeling."
3. "Let's finish the preoperative teaching."
4. "You're lucky to have a wife to care for you."
Encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, "At least you will still have one good leg to use," that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term "invalid." The nurse needs to focus on this concern and not try to complete the teaching first before discussing what is on the client's mind. The client's needs, not the nurse's needs, must be met first. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the client's wife caring for him may reinforce the client's feelings of helplessness as an invalid.
The client asks the nurse, "Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?" On which of the following should the nurse base the response?
1. The need to remove as much of the leg as possible.
2. The adequacy of the blood supply to the tissues.
3. The ease with which a prosthesis can be fitted.
4. The client's ability to walk with a prosthesis.
The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the client's ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant.
A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should:
1. Elevate the stump.
2. Reinforce the dressing.
3. Call the surgeon.
4. Draw a mark around the site.
The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identified, the surgeon should be notified. The stump is not elevated because adhesions may occur, interfering with the ability to fit a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing.
A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first?
1. Tell the client it is impossible to feel the pain.
2. Show the client that the toes are not there.
3. Explain to the client that her pain is real.
4. Give the client the prescribed opioid analgesic.
The nurse's first action should be to administer the prescribed opioid analgesic to the client, because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.
The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches?
1. Abdominal exercises.
2. Isometric shoulder exercises.
3. Quadriceps setting exercises.
4. Triceps stretching exercises.
Use of crutches requires significant strength from the triceps muscles. Therefore, efforts are focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-ups are excellent exercises targeted at the triceps muscles. Abdominal exercises, range-of-motion and isometric exercises of the shoulders, and quadriceps and gluteal setting exercises are not helpful in preparing for crutch walking.
The nurse teaches a client about using the crutches, instructing the client to support her weight primarily on which of the following body areas?
1. Axillae.
2. Elbows.
3. Upper arms.
4. Hands.
When using crutches, the client is taught to support her weight primarily on the hands. Supporting body weight on the axillae, elbows, or upper arms must be avoided to prevent nerve damage from excessive pressure.
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions?
1. Determining the client's knowledge level about cholesterol.
2. Asking the client to name foods that are high in fat, cholesterol, and salt.
3. Explaining the importance of complying with the diet.
4. Assessing the client's and family's typical food preferences.
Before beginning dietary instructions and interventions, the nurse must first assess the client's and family's food preferences, such as pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base.