Mosby's Comprehensive Review of Radiography

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* Evolve Student Resources are provided free with each NEW book purchase only. Mosby’s Comprehensive Review of Radiography The Complete Study Guide and Career Planner Seventh Edition This page intentionally left blank Mosby’s Comprehensive Review of Radiography The Complete Study Guide and Career Planner

Seventh Edition

William J. Callaway, MA, RT(R) Radiography Educator, Author, Speaker Springfield, Illinois 3251 Riverport Lane St. Louis, Missouri 63043

MOSBY’S COMPREHENSIVE REVIEW OF RADIOGRAPHY: THE COMPLETE STUDY GUIDE AND CAREER PLANNER, SEVENTH EDITION ISBN: 978-0-323-35423-3

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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Callaway, William J. (William Joseph), 1951- , author. Mosby’s comprehensive review of radiography : the complete study guide and career planner / William J. Callaway. -- Seventh edition. p. ; cm. Comprehensive review of radiography Includes bibliographical references and index. ISBN 978-0-323-35423-3 (pbk. : alk. paper) I. Title. II. Title: Comprehensive review of radiography. [DNLM: 1. Radiography--Examination Questions. 2. Technology, Radiologic-- Examination Questions. 3. Vocational Guidance--Examination Questions. WN 18.2] RC78.17 616.07’572076--dc23 2015036336

Content Strategist: Sonya Seigafuse Content Development Manager: Billie Sharp Content Development Specialist: Sarah Vora Publishing Services Manager: Hemamalini Rajendrababu Senior Project Manager: Kamatchi Madhavan Design Direction: Ashley Miner

Printed in United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1 About the Author

William J. Callaway, MA, RT(R), has been involved in radi- He is widely known for his conference presentations ography education for more than 40 years. He has directed for students, educators, and practicing technologists at both collegiate associate degree and hospital-sponsored radi- international, national, state, and local radiologic technol- ography programs in addition to teaching the subjects cov- ogy meetings. He has given more than 500 presentations, ered in this text. He is co-author of Introduction to Radiologic which include “Pass It the First Time: Preparing for the Technology, also published by Elsevier, and has had writings Certification Exam”; “And You Thought X-Ray Physics Had published in state and national radiologic technology jour- to Be Boring!”; “It’s More Than a Smile: A Fresh Perspective nals. Mr. Callaway has held elected office in the Association on Patient Care”; “Giving Effective Conference Presenta- of Collegiate Educators in Radiologic Technology (ACERT) tions”; and “Win That Job!” and the Association of Educators in Imaging and Radiologic Sciences (AEIRS).

v This page intentionally left blank To our family’s next generation, our grandchildren: Alex, Kailin, Mariah, Jacob, Mikella, Makenna, Troy, Madalyn, and Freddy This page intentionally left blank Reviewers

Karen Callaway, MA, SPHR Anna N. Phillips, MS, RT(R)(CT) Executive Vice President, Organizational Strategy Department Head H.D. Smith Radiography Springfield, Illinois Randolph Community College Asheboro, North Carolina Mary Ellen Carpenter, MA, RT(R)(CV)(CT) Radiography Program Directory Jeannean Hall Rollins, MRC, RT(R)(CV)(ARRT) Essex County College Associate Professor Newark, New Jersey Medical Imaging and Radiation Sciences Arkansas State University Tammara M. Chaffee, M.Ed, RT(R)(M) Jonesboro, Arkansas Assistant Professor Dona Ana Community College Breanna Wright Las Cruces, New Mexico Radiologic Technologist Student Medical Imaging and Radiologic Sciences Tiffany Goodwin, RT(R) Arkansas State University Radiologic Technologist Jonesboro, Arkansas Poplar Bluff, Missouri

Jim Partin, RT(R) Radiology Instructor Spencerian College Louisville, Kentucky

ix This page intentionally left blank Preface

Content and Organization New Content and Features Completely updated for the latest certification exam speci- This new edition is written to the latest radiography exam fications, Mosby’s Comprehensive Review of Radiography is content specifications used by the ARRT effective Janu- designed for students as a study guide throughout their radi- ary 1, 2017, making this the most up-to-date review book ography education and as a review book as they prepare to available. Coverage of digital imaging, already included in take the Registry examination. previous editions, has been once again updated to reflect Part I begins right where students need to begin, guiding its importance on the certification exam. The relative num- them through an assessment of their study skills and time ber of questions asked in each of the four new ARRT con- management, both critical to success in the radiography tent categories has been updated in the challenge tests in program and reviewing. The complete topic outline of the chapter 6 as well as the tests on Evolve. New ARRT ques- radiography exam administered by the American Registry of tion formats are included, such as exhibits, sorted list, Radiologic Technologists (ARRT) is provided to help stu- multi-select, and combined response. The relative number dents visualize the breadth of information they need to mas- of questions asked in each of the four new ARRT con- ter. Tips on answering questions ensure that students will be tent categories has been updated in the challenge tests in able to manage the styles of questions they will encounter chapter 6 as well as the tests on Evolve. New ARRT ques- on the ARRT exam. tion formats are included, such as exhibits, sorted list, The highlight of Part I is a comprehensive review, in out- multi-select, and combined response. line form, of the major content areas covered on the ARRT One of the most popular features of this study guide is exam in radiography. Each content review is followed by a the material available on the Evolve website. Those ques- set of 100 questions related specifically to that topic. After tions can be accessed anywhere the student has Internet students have reviewed all subject areas, they are ready to access, whether at home or in the palm of the hand. These take the three 200-question challenge tests in Chapter 6. All questions are designed to simulate the computer-based questions are written in formats used by the ARRT. Answers exam administered by the ARRT. In tutorial mode, students and rationales for the review questions and challenge tests may answer hundreds of multiple-choice questions for are provided in the appendix. each ARRT content area. Rationales and study tips provide To prepare students to master the material and be fully immediate feedback, and questions can be bookmarked for prepared for the Registry exam, the Evolve website that later reference. In test mode a virtually unlimited number accompanies the text provides hundreds of additional ques- of randomly generated 200-question multiple-choice exams tions based on the Registry exam content outline and writ- are available. ten in formats used by the ARRT. These resources make this the premier radiography Unlike other review books, Mosby’s Comprehensive Review review book and study guide, all in one product. of Radiography also serves students as a career planner. Part II, Career Planning, provides students the oppor- How to Use This Book tunity to inventory their interests and set goals for professional development. It gives suggestions for satisfying This study guide is particularly effective for use throughout professional continuing education requirements. Valu- the radiography program. The content outline may be ref- able information and resources on radiologic specialties erenced as a supplement to courses in the radiography cur- and academic degrees are presented to further assist stu- riculum. The study questions are excellent aids to learning dents with career planning. Part II also offers examples in all of the subject areas. of actual resumes and important information and tips on As a review book, this text provides a logical, well- interviewing. To further ease the transition into the health thought-out approach to preparing for the Registry exam. care workplace, Part II describes employer expectations in The content outline, so effective throughout the educational detail. No other book provides all of this valuable informa- program, is particularly appreciated at review time. Con- tion to help students make the transition into their careers tent that may be tested is presented in a format that is easy as practicing radiographers. to use and understand. Because I teach these subjects, my

xi xii Preface

approach to the reader is the same as if class were being held publications. Permission to reproduce ARRT copyrighted each time the book is opened. I have provided rationales materials within this publication should not be construed as to answers where appropriate. In most cases, I provide key an endorsement of the publication by the ARRT. points regarding the answer, study suggestions, or both. For other questions, such as labeled drawings or radiographs, Acknowledgments the answers may be obvious and do not require a detailed explanation. You will also encounter facts asked in multiple Elsevier once again assembled a great team to bring this ways, challenging you to think about information in dif- project to fruition. Special acknowledgment goes to Sonya ferent ways. This will help prepare you for whatever form Seigafuse and Billie Sharp for their leadership and enthusi- the questions may be asked on the certification examination astic support of this text. Sarah Vora provided expert edit- and will also reinforce the material by causing you to inter- ing, as well as guided manuscript development throughout act with it more than once. In any case, be sure to return this entire project. Kamatchi Madhavan moved the project to the chapter and use the study outline for detailed review toward completion by providing copyedited chapters and and to reinforce concepts, facts, and illustrations that need page proofs in a timely and workable manner. Given the extra attention. talents of the entire Elsevier staff, any errors or omissions Care has been taken to create questions that cover the from this book are solely mine. primary information taught in radiography programs and I extend my thanks to the hundreds of educators and that are therefore relevant to the ARRT exam. This phi- tens of thousands of students who have used this text and losophy, coupled with the outline form, helps students given it their overwhelming support. Their positive com- make optimal use of study time. Explanations of answers ments and suggestions have been incorporated and make are written in the same style I use in my own classes. This it better than ever. I express my sincere appreciation to the student-friendly approach will be appreciated for its direct reviewers for going over this text line by line and question communication to the users of this text. Students who have by question. difficulty understanding an answer are advised to return to Very special recognition goes to my family for their love the study guide for additional review. This text should not and support of my professional endeavors, from speaking to be viewed as a substitute for a textbook or coursework that writing. Thanks to my wife, Karen; our children Amy, Cara, comprehensively covers a subject area. David, Adam, and Kim; and our grandchildren Alex, Kailin, A final note on the use of this guide: Variation in the Mariah, Jacob, Mikella, Makenna, Troy, Madalyn, and details of test content occurs across certification exams. Freddy. A very special recognition goes to Tootsie for keep- Therefore inclusion of specific information in this guide ing me company during extended hours at the computer. does not guarantee that it will be tested, and the exclusion of certain information is not meant to suggest its absence from William J. Callaway the exam. The ARRT does not review, evaluate, or endorse Contents

Part I: Review and Study Guide 1 9 Interviewing Techniques 217

1 Preparation for Review 2 10 Employment Expectations 221

2 Patient Care 15 Appendixes

3 Safety 39 Answers to Review Questions 228

4 Image Production 58 Bibliography 250 Illustration Credits 251 5 Procedures 91 Index 252 6 Challenge Tests 154 Please note: Part II: Career Planning 195 The ARRT does not review, evaluate, or endorse publications. Permission to reproduce ARRT copyrighted materials within 7 Career Paths 196 this publication should not be construed as an endorsement of the publication by the ARRT. 8 Writing a Professional Resume 210

xiii PART I

Review and Study Guide

1 1 Preparation for Review

Welcome to Your Study Guide and Career recertification, this important topic is included inChapter 7, Planner! “Career Paths.” Chapter 7 also addresses advanced-level exams, academic degrees, and many options available to you Congratulations on acquiring the most complete study as you plan your professional career. guide available to prepare for radiography classes through- If you are using this text as a program-long study guide, out the educational program and to master the radiography you will want to become familiar with Chapters 2, 3, 4, and certification exam. This student-friendly guide, coupled 5 quickly. These chapters may be used as a supplement to with your commitment to excellence and management of the text you have for each course in your program. They are study time, will take you on a journey culminating in the effective for a quick overview of subject matter and a review achievement of your goals. before a quiz or test. Whether using this guide throughout By reviewing the major subject areas contained in Part the program or as a Registry review, be sure to take time One, “Review and Study Guide,” of this book, answering with the rest of Chapter 1. A key to success in your classes and studying the exam questions in the text and online and the radiography exam is prioritizing and managing your resource, and understanding the skills involved in vari- time. Investing time now in this chapter will pay big divi- ous areas of radiography, you will be well on your way dends as your review process moves along in an organized to achieving the goal of excelling in class and passing the fashion. radiography exam. Passing the courses and the exam is only one of several steps in building your new career, however. As you look Prioritizing Subjects and Scheduling toward graduation, you are probably contemplating your Study Time transition into the work environment or considering further education. In addition to preparing you thoroughly for Determining the Length of Review the exam, this book helps you develop your career goals. In Part Two, “Career Planning,” you will have an opportunity As you begin the task of planning your review for the to describe the events that have been rewarding and moti- ARRT exam, take a few moments to think about how you vating during your education. This activity will enable you want to go about the review process. It is never too early to set goals for establishing your practice of medical radi- to begin studying for the exam. Because you may take the ography and to plan for either immediate employment or exam immediately after graduation, you will probably want continued education. to begin your review very soon. If you are also using this The most important tools used during the transition text as a study guide throughout your radiography program, into the workforce are the resume and the interview, which you are already becoming familiar with the topics and use are covered in Chapters 8 and 9 to prepare you thoroughly of the book. Most radiography educators recommend that for marketing yourself in today’s ever-changing health care students begin a well-thought-out review approximately environment. So that you may be fully aware of your role 6 months before taking the exam. Not all students require as an entry-level radiographer, Chapter 10 is dedicated to that much time to prepare adequately; students who are bet- helping you anticipate on-the-job expectations for your ter able to retain the material they have already learned may first postgraduate position. The competitive and, at times, complete their review more quickly. chaotic nature of health care delivery requires that you Another factor that can greatly influence how far in understand these expectations well as you prepare your first advance you should begin studying is the amount of time resume or have your first interview. This information is pre- you have available. In all likelihood, you are beginning to sented to ease your transition from student to entry-level review while still taking other courses in your educational radiographer. program. Those courses must be given a high priority as you Because the American Registry of Radiologic Technolo- begin budgeting your time. It does little good to review for gists (ARRT) requires proof of continuing education for the certification exam only to find that you are hopelessly

2 Chapter 1 Preparation for Review 3 behind in another required course. In addition, you may Strongest Subjects have employment obligations that take up a considerable ______amount of time or family commitments that must not be ______allowed to falter while you prepare for the exam. Be aware, ______however, that exam preparation takes a lot of time and that ______your success depends on it. ______Begin reviewing at least 6 months before the exam. If you need to begin reviewing earlier, based on the exercises that Look again at the entries you made. Transfer these sub- follow, then do so. If you finish your review before 6 months jects to the spaces that follow, ranking the weakest subjects is up, you can either stop reviewing or go back over the first. Then progress in order to the subjects in which you are material in less detail one more time. If you wait to begin strongest. reviewing only 3 or 4 months before the exam, you may have insufficient time to go over the material thoroughly Priority of Study Topics, Weakest to Strongest and, as a result, may need to postpone your exam date. I need to study the following subjects in this order: Before you begin budgeting your review time, consider ______the suggestions and encouragement provided by your ______instructors, who probably have several years’ experience in ______working with students about to prepare for the exam. Their ______wisdom and advice should be taken seriously. If you follow ______the routine they suggest and the guidelines contained in this ______review book, you should be more than adequately prepared ______to pass the exam. Remember, however, that managing the ______quality and quantity of your review time is ultimately up to ______you. Although your educational program may include some ______review classes, do not rely on them alone. Your own personal ______review is crucial to passing the exam. Now that you have successfully reached this point in your educational program, The rationale for studying more difficult content first is you should use your energy, time, and skills wisely during twofold: (1) The more difficult material will require more time, these final months of preparation. Just as with running a race, which you will have in greater supply at the beginning of the finish strong! 6-month period than at the end; (2) if you have had serious difficulty with some of the subject areas and you study those first, you will have additional time to seek explanation from your Planning the Review Process instructors and to read the material again. Save for last the subjects with which you are most comfortable. These will require If one advances confidently in the direction of his dreams, the least amount of study time and, if your time becomes lim- and endeavors to lead the life which he has imagined, he ited, reviewing them quickly will not be as detrimental. will meet with a success unexpected in common hours. The time you spend now on planning a study calendar HENRY DAVID THOREAU and prioritizing your study needs will pay great dividends as you begin the review process. Such planning should allow It is now time to turn your attention to the review process you to proceed more efficiently and dedicate more time to and begin to set priorities. Look through the chapters con- studying. If you are not filling in a calendar or prioritizing taining the review material if you have not already done so. your study needs as you read this chapter, take the time right In the following space provided, make a list of the subject now to select a day and time within the next 5 days when areas in which you feel particularly strong or weak. By listing you will reread Chapter 1 and follow the directions for time the subject areas in this way, you will be able to prioritize the management and prioritizing. material you need to cover. Second-year radiography stu- ______I have completed my planner calendar and priori- dents preparing for the exam commonly make the mistake tized my subject areas for study. of reviewing the easiest material first. This is the opposite of ______I will complete my planner calendar and prioritize what you should do. my subject areas for study on ______(day), ______(date) at ______a.m./p.m. Weakest Subjects Now that you have established your priorities or made an ______appointment with yourself to plan your calendar, you have ______set your first goal for reviewing and passing the certification ______exam. Even more important, you have taken the initial step ______toward your first radiography job or continued education. ______Be sure to congratulate yourself on accomplishing this task, and then finish reading this chapter. 4 PART 1 Review and Study Guide

Although some may scoff at your calendar planning you attempt to budget your review time. Pause now to con- and the amount of time you choose to spend reviewing, sider each of them carefully. others may feel you are not spending enough time pre- If you are already using some form of a daily, weekly, paring. If you are receiving conflicting advice, you may or monthly calendar, either on paper or on an electronic become confused by all of the suggestions, hints, and device, to plan your study time, you simply need to decide guidelines. You should refer to the suggestions made by where within your study schedule to include your review. your instructors and the suggestions contained in this If you have not been using a calendar to budget your study guide. time, this is a great time to start. You don’t have to buy an expensive time planner. Most students use a calendar with Scheduling Your Study Time squares large enough to write in times and planned activities. Others plan their time using the software in their Go through the process of planning your study time and particular brand of smartphone, tablet, or other mobile evaluating your commitments so that you may set goals device. Figure 1-1 is an example of a tablet-based calen- for reviewing all of the material. Browse through Chap- dar being used to budget time for current classes and for ters 2 through 5 and briefly refresh your memory about review. the topics. Are there large amounts of information that The importance of writing study time on a calendar can- you can’t recall? Is information there that you have never not be overemphasized. You are much more likely to adhere seen before? Does most of it look familiar, and is it easy to a study schedule if you have thought it through, written to recall? it down, and posted it where you see it daily. It is highly Try answering a few of the exam questions after each sec- recommended that once you plan your review time, you tion, and sample some of the questions from the compre- print a copy of your calendar and give it to your instruc- hensive exams in Chapter 6. Were you able to answer the tor. Educators can be powerful motivators by occasionally questions easily? Do you feel confident about your answers, reminding a student of a written commitment to review. or were they educated guesses? How many did you get cor- Filling in a calendar in this way is also a form of establishing rect compared with the number you missed? Are there spe- a written contract with yourself. In so doing, you recog- cific subject areas in which you feel particularly strong or nize that only you are ultimately responsible for covering the weak? Will you need to spend more time studying one area review material. If the college or hospital you are attending than another? You have to answer all of these questions as provides you access to a study skills department, meet with

• Figure 1-1 Calendar for scheduling study time. Chapter 1 Preparation for Review 5 one of the professionals there, share your ideas for time and exam was particularly easy and that you should not worry study management, and gain even more support for attain- about it. You may also be surprised to hear such comments ing your goals. as “There was almost no positioning on the exam” or “It When you are setting up a review calendar, being regu- was all physics!” The radiography exam adheres to content lar and consistent is important. Set aside specific times to specifications that are included in this chapter. In most review on a regular basis. Don’t save review for times when cases, when test takers think one category had significantly you have nothing else to do. State your commitment in such more questions than another category, this is a reflection of terms as the following: “I will review physics every Thurs- their command of the category’s content or of their prepa- day evening for the next 8 weeks for approximately 2 hours ration, or lack thereof, for the exam. Although individu- each time.” This contract with yourself describes the activity, als who are providing you with feedback about the exam the time commitment, and the subject involved. Avoid such may have good intentions, the reliability of their memory entries as “I will study physics four times this month.” There of the exam items is questionable. Besides, because of the is little commitment to that statement, and the goal it sets size of the item bank for the exam, the questions vary each forth is not likely to be accomplished. time the exam is administered. Even if the individuals with As an adult learner, you have probably developed an whom you are speaking accurately recall the exam content, awareness of your strengths and weaknesses relative to time you will not be answering the same set of questions on your management and commitment to studies. Whatever your exam. Each radiography exam is different from the preced- self-appraisal, the fact that you are using this book suggests ing exam. that you are a successful student with the capability to man- Most importantly, you should be aware that passing age your time effectively. You should now spend some time along test question content is a violation of the ARRT applying your scheduling and time management skills to Standards of Ethics, specifically addressed in the Rules of the planning of your review. Ethics. It is best to avoid such conversations from both If you are allotting at least 6 months to prepare for the preparation and ethical standpoints. Finally, by choosing exam, you should have plenty of time to cover all of the to ignore advice from even the most well-intentioned per- material and take and review the exams in this book and son who has recently taken the exam and instead following online. If you do all of the expected regular studies and the study routine that you are planning under the guidance review, you should have little difficulty on the exam. I hope of your instructors and this book, you will guarantee that that by the time you take the exam, you will regard it as just you are the one controlling the exam outcome and can be another quiz. assured that you are undertaking the best preparation for the exam. Study Habits A few reminders about study habits or study conditions are in order. Remember to choose your most difficult sub- Study habits mirror the individuality of each student. Some jects to study first. You have already listed these in the pre- students prefer to study alone. They may read small sections vious section. When you study, be sure you have set aside of a chapter at a time, pausing to reflect on the content and time when you can be quiet with no interruptions. Some taking additional notes, if necessary, or they may recite the people study better with soft music in the background, material aloud. Others choose to read over a section or an whereas others prefer silence. Other types of music and entire chapter many times, reviewing the material to facili- television simply interfere with concentration. Although tate their recall. Some students find it helpful to study in you should be comfortable while studying, you should groups, taking turns quizzing one another and answering not be too comfortable. Remaining upright is particularly practice questions. important. By now, you probably have formed your own set of Take regular but infrequent breaks. Be sure that light- effective study habits. In using this book to prepare for ing is adequate and the room temperature is controllable the exam, you should consider every suggestion that may and comfortable. Arrange the study conditions so that improve your method of study. However, do not greatly you can focus all of your attention on what you are doing. alter study habits that have already proved successful. Regardless of the study method used, quiet concentration Also, keep in mind that as you review for the exam, you is of utmost importance. You may wish to reinforce your should not be learning new material. By definition, a learning by reciting the material aloud—a practice requir- review should be a revisiting of material that you have ing a study setting that is isolated and free from distrac- already learned and learned well. In addition, your review tions. In addition, study at the time of day when your should be as comprehensive as possible, including all of mind is most alert. Some students prefer to study early in the topics. the morning, whereas others have found that they study Before discussing study habits, let’s address concerns better later in the afternoon or early evening. Cramming that many second-year students have after talking with oth- late at night or into the early hours of the morning is inef- ers who have recently taken the exam. You may have been fective for most individuals. Besides, if review is a prior- told to give little attention to certain subject areas because ity, you will want to assign it an important place in your they did not appear on the exam. You may hear that the schedule. 6 PART 1 Review and Study Guide

Exam Specifications constructed, and the relative importance of each is weighted. The review of the major categories on the exam is covered in Although the specifications for the ARRT radiography exam the next four chapters. (Table 1-1) do not divulge specific questions, they do give the reader the outline from which the exam is constructed. Analysis of Category Components In addition, the approximate number of questions in each category is listed to allow you to see the relative importance An approximate number of questions for each of the major placed on the different subject areas. subject areas is shown in the detailed list that follows.* The number of questions of subcategory content within the KEY REVIEW POINTS major areas are general guidelines and may vary to a certain extent with each exam administration. Reviewing

• Begin at least 6 months before test day. Patient Care (33 questions) • Perform an inventory of strengths and weaknesses by topic. 1. Patient Interactions and Management (33) • Commit your study schedule to a calendar. • Base your review on ARRT exam specifications; avoid A. Ethical and Legal Aspects coaching from previous test takers. 1. Patient’s Rights • Use study habits that have proven successful in the past. a. informed consent (e.g., written, oral, implied) • Study difficult subjects first. • Study with no interruptions. b. confidentiality (HIPAA) • Be comfortable when studying, but not too comfortable. c. American Hospital Association (AHA) Patient Care • Review during the time of day when you are most alert. Partnership (Patient’s Bill of Rights) 1. privacy 2. extent of care (e.g., DNR) 3. access to information You may wonder why these particular categories were 4. living will, health care proxy, advanced directives selected for the exam and are weighted in this way. The ARRT 5. research participation periodically performs an extensive study called a task inventory. 2. Legal Issues The result (see Chapter 10) for radiographers lists all of the spe- a. verification (e.g., patient identification, compare order to cific skills normally performed by an entry-level radiographer. clinical indication) The skills in the task inventory should coincide with the b. common terminology (e.g., battery, negligence, mal- terminal competencies of all approved educational programs. practice, beneficience) From this task inventory, the categories for the exam are c. legal doctrines (e.g., respondeat superior, res ipsa loquitur) TABLE d. restraints versus immobilization 1-1 Specifications for the ARRT Radiography Exam e. manipulation of electronic data (e.g., exposure indicator, processing algorithm, brightness and contrast, Number cropping or masking off anatomy) of Scored 3. ARRT Standards of Ethics Content Category Questions

Patient Care 33 B. Interpersonal Communication Patient Interactions and Management 1. Modes of Communication Safety 53 a. verbal/written Radiation Physics and Radiobiology b. nonverbal (e.g., eye contact, touching) Radiation Protection 2. Challenges in Communication Image Production 50 a. interaction with others Image Acquisition and Technical Evaluation 1. language barriers Equipment Operation and Quality Assurance 2. cultural and social factors Procedures 64 3. physical or sensory impairments Head, Spine, and Pelvis Procedures 4. age Thorax and Abdomen Procedures 5. emotional status, acceptance of condition Extremity Procedures b. explanation of medical terms Total 200 c. strategies to improve understanding

From The American Registry of Radiologic Technologists® Radiography examination content specifications, St Paul, MN, 2015. Implementation * From American Registry of Radiologic Technologists: Radiography exam- date January 2017. ination content specifications, St Paul, MN, 2015, ARRT. Implementation date January 2017. Chapter 1 Preparation for Review 7

3. Patient Education c. safe injection practices a. explanation of current procedure (e.g., purpose, exam d. safe handling of contaminated equipment/surfaces length) e. disposal of contaminated materials b. verify informed consent when necessary 1. linens c. pre- and post-examination instructions (e.g., prep- 2. needles aration, diet, medications and discharge instruc- 3. patient supplies tions) 4. blood and body fluids d. respond to inquiries about other imaging modalities 4. Transmission-Based Precautions (e.g., CT, MRI, mammography, sonography, nuclear a. contact medicine, bone densitometry regarding dose differ- b. droplet ences, types of radiation, patient preps) c. airborne 5. Additional Precautions C. Physical Assistance and Monitoring a. neutropenic precautions (reverse isolation) 1. Patient Transfer and Movement b. healthcare associated (nosocomial) infections a. body mechanics (e.g., balance, alignment, movement) b. patient transfer techniques F. Handling and Disposal of Toxic or Hazardous 2. Assisting Patients with Medical Equipment Material a. infusion catheters and pumps 1. Types of Materials b. oxygen delivery systems a. chemicals c. other (e.g., nasogastric tubes, urinary catheters, tra- b. chemotherapy cheostomy tubes) 2. Safety Data Sheet (e.g., material safety data sheets) 3. Routine Monitoring a. vital signs G. Pharmacology b. physical signs and symptoms (e.g., motor control, 1. Patient History severity of injury) a. medication reconciliation (current medications) c. fall prevention b. premedications d. documention c. contraindications d. scheduling and sequencing exams D. Medical Emergencies 2. Administration 1. Allergic Reactions (e.g., contrast media, latex) a. routes (e.g., IV, oral) 2. Cardiac or Respiratory Arrest (e.g., CPR) b. supplies (e.g., enema kits, needles) 3. Physical Injury or Trauma 3. Venipuncture 4. Other Medical Disorders (e.g., seizures, diabetic reactions) a. venous anatomy b. supplies E. Infection Control c. procedural technique 1. Cycle of Infection 4. Contrast Media Types and Properties (e.g., iodinated, a. pathogen water soluble, barium, ionic versus non-ionic) b. reservoir 5. Appropriateness of Contrast Media to Exam c. portal of exit a. patient condition (e.g., perforated bowel) d. mode of transmission b. patient age and weight 1. Direct c. laboratory values (e.g., BUN, creatinine, GFR) a. droplet 6. Complications/Reactions b. direct contact a. local effects (e.g., extravasation/infiltration, phlebitis) 2. Indirect b. systemic effects a. airborne 1. mild b. vehicle borne-fomite 2. moderate c. vector borne-mechanical or biological 3. severe e. portal of entry c. emergency medications f. susceptible host d. radiographer’s response and documentation 2. Asepsis Safety (53 questions) a. equipment disinfection b. equipment sterilization Radiation Physics and Radiobiology (22) c. medical aseptic technique A. Principles of Radiation Physics d. sterile technique 1. X-Ray Production 3. CDC Standard Precautions a. source of free electrons (e.g., thermionic emission) a. hand hygiene b. acceleration of electrons b. use of personal protective equipment (e.g., gloves, c. focusing of electrons gowns, masks) d. deceleration of electrons 8 PART 1 Review and Study Guide

2. Target Interactions 3. Beam Restriction a. bremsstrahlung a. purpose of primary beam restriction b. characteristic b. types (e.g., collimators) 3. X-Ray Beam 4. Filtration a. frequency and wavelength a. effect on skin and organ exposure b. beam characteristics b. effect on average beam energy 1. quality c. NCRP recommendations (NCRP #102, minimum 2. quantity filtration in useful beam) 3. primary versus remnant (exit) 5. Patient Considerations c. inverse square law a. positioning d. fundamental properties (e.g., travel in straight lines, b. communication ionize matter) c. pediatric 4. Photon Interactions with Matter d. morbid obesity a. Compton effect 6. Radiographic Dose Documentation b. photoelectric absorption 7. Image Receptors c. coherent (classical) scatter 8. Grids d. attenuation by various tissues 9. Fluoroscopy 1. thickness of body part a. pulsed 2. type of tissue (atomic number) b. exposure factors c. grids B. Biological Aspects of Radiation d. positioning 1. SI Units of Measurement e. fluoroscopy time a. absorbed dose f. automatic brightness control (ABC) or automatic b. dose equivalent exposure rate control (AERC) c. exposure g. receptor positioning d. effective dose h. magnification mode e. air kerma i. air kerma display 2. Radiosensitivity j. last image hold a. dose-response relationships k. dose or time documentation b. relative tissue radiosensitivities (e.g., LET, RBE) l. minimum source-to-skin distance (21 CFR) c. cell survival and recovery (LD50) 10. Dose Area Product (DAP) Meter d. oxygen effect 3. Somatic Effects B. Personnel Protection a. short-term versus long-term effects 1. Sources of Radiation Exposure b. acute versus chronic effects a. primary x-ray beam c. carcinogenesis b. secondary radiation d. organ and tissue response (e.g., eye, thyroid, breast, 1. scatter bone marrow, skin, gonadal) 2. leakage 4. Acute Radiation Syndromes c. patient as source a. hematopoietic 2. Basic Methods of Protection b. gastrointestinal (GI) a. time c. central nervous system (CNS) b. distance 5. Embryonic and Fetal Risks c. shielding 6. Genetic Impact 3. Protective Devices a. genetic significant dose a. types b. goals of gonadal shielding b. attenuation properties 2. Radiation Protection (31 questions) c. minimum lead equivalent (NCRP #102) 4. Special Considerations A. Minimizing Patient Exposure (ALARA) a. mobile units 1. Exposure Factors b. fluoroscopy a. kVp 1. protective drapes b. mAs 2. protective Bucky slot cover c. automatic exposure control (AEC) 3. cumulative timer 2. Shielding 4. remote-controlled fluoroscopy a. rationale for use c. guidelines for fluoroscopy and mobile units (NCRP b. types #102, 21 CFR) c. placement Chapter 1 Preparation for Review 9

C. Automatic Exposure Control (AEC) 1. fluoroscopy exposure rates (normal and high-level control) 1. Effects of Changing Exposure Factors on Radiographic 2. exposure switch guidelines Quality 5. Radiation Exposure and Monitoring 2. Detector Selection a. dosimeters 3. Anatomic Alignment 1. types 4. Exposure Adjustment (e.g., density, +1 or −1) 2. proper use D. Digital Imaging Characteristics b. NCRP recommendations for personnel monitoring (NCRP #116) 1. Spatial Resolution (equipment related) 1. occupational exposure a. pixel characteristics (e.g., size, pitch) 2. public exposure b. detector element (DEL) (e.g., size, pitch, fill factor) 3. embryo/fetus exposure c. matrix size 4. dose equivalent limits d. sampling frequency 5. evaluation and maintenance of personnel dosim- 2. Contrast Resolution (equipment related) etry records a. bit depth 6. handling and disposal of radioactive material b. modulation transfer function (MTF) c. detective quantum efficiency (DQE) Image Production (50 questions) 3. Image Signal (exposure related) 1. Image Acquisition and Technical Evaluation (21) a. dynamic range A. Selection of Technical Factors Affecting b. quantum noise (quantum mottle) Radiographic Quality c. signal-to-noise ratio (SNR) d. contrast-to-noise ratio (CNR) (X indicates topics covered on the examination.) E. Image Identification Factors Affecting Radiographic Quality 1. Methods (e.g., radiographic, electronic) 2. Legal Considerations (e.g., patient date, examination data) 1. 3. Receptor 2. Spatial 4. Exposure Contrast Resolution Distortion 2. Equipment Operation and Quality a. mAs X Assurance (29 questions) b. kVp X X A. Imaging Equipment c. OID X (air X X gap) 1. Components of Radiographic Unit (fixed or mobile) d. SID X X X a. operating console e. focal spot size X b. x-ray tube construction f. grids* X X 1. electron source g. tube filtration X X 2. target materials h. beam restriction X X 3. induction motor i. motion X c. automatic exposure control (AEC) j. anode heel effect X 1. radiation detectors k. patient factors X X X X 2. back-up timer (size, pathology) 3. exposure adjustment (e.g., density, +1 or −1) l. angle (tube, part, X X 4. minimum response time or receptor) d. manual exposure controls *Includes conversion factors for grids. e. beam restriction 2. X-Ray Generator, Transformers, and Rectification System a. basic principles B. Technique Charts b. phase, pulse, and frequency 1. Anatomically Programmed Technique c. tube loading 2. Caliper Measurement 3. Components of Fluoroscopic Unit (fixed or mobile) 3. Fixed Versus Variable kVp a. image receptors 4. Special Considerations 1. image intensifier a. casts 2. flat panel b. pathologic factors b. viewing systems c. age (e.g., pediatric, geriatric) c. recording systems d. body mass index (BMI) d. automatic brightness control (ABC) or automatic e. contrast media exposure rate control (AERC) 10 PART 1 Review and Study Guide

e. magnification mode 6. Distortion (e.g., size, shape) f. table 7. Identification Markers (e.g., anatomic side, patient, date) 4. Components of Digital Imaging 8. Image Artifacts a. CR components 9. Radiation Fog 1. plate (e.g., photo-stimulable phosphor (PSP)) 2. plate reader D. Quality Control of Imaging Equipment and b. DR image receptors Accessories 1. flat panel 1. Beam Restriction 2. charge coupled device (CCD) a. light field to radiation field alignment 3. complementary metal oxide semiconductor (CMOS) b. central ray alignment 5. Accessories 2. Recognition and Reporting of Malfunctions a. stationary grids 3. Digital Imaging Receptor Systems b. Bucky assembly a. maintenance (e.g., detector calibration, plate reader c. compensating filters calibration) b. QC tests (e.g., erasure thoroughness, plate uniformity, B. Image Processing and Display spatial resolution) 1. Raw Data (pre-processing) c. display monitor quality assurance (e.g., grayscale stan- a. analog-to-digital convertor (ADC) dard display function, luminance) b. quantization 4. shielding accessories (e.g., lead apron, glove testing) c. corrections (e.g., rescaling, flat fielding, dead pixel correction) Procedures (64 questions) d. histogram 2. Corrected Data for Processing This section addresses imaging procedures for the ana- a. grayscale tomic regions listed below. Questions cover the following b. edge enhancement topics: c. equalization 1. Positioning (e.g., topographic landmarks, body positions, d. smoothing path of central ray, immobilization devices, respiration) 3. Data for Display 2. Anatomy (e.g., including physiology, basic pathology, a. values of interest (VOI) and related medical terminology) b. look-up table (LUT) 3. Procedure adaptation (e.g., body habitus, body mass 4. Postprocessing index, trauma, pathology, age, limited mobility) a. brightness 4. Evaluation of displayed anatomic structures (e.g., b. contrast patient positioning, tube-part-image receptor alignment) c. region of interest (ROI) d. electronic cropping or masking Head, Spine, and Pelvis Procedures (18 questions) e. stitching 5. Display Monitors A. Head a. viewing conditions (e.g., viewing angle, ambient 1. Skull lighting) 2. Facial Bones b. spatial resolution (e.g., pixel size, pixel pitch) 3. Mandible c. brightness and contrast 4. Zygomatic Arch 6. Imaging Informatics 5. Temporomandibular Joints a. DICOM 6. Nasal Bones b. PACS 7. Orbits c. RIS (modality work list) 8. Paranasal Sinuses d. HIS B. Spine and Pelvis e. EMR or EHR 1. Cervical Spine 2. Thoracic Spine C. Criteria for Image Evaluation of Technical 3. Scoliosis Series Factors 4. Lumbar Spine 1. Exposure Indicator 5. Sacrum and Coccyx 2. Quantum Noise (quantum mottle) 6. Myelography 3. Gross Exposure Error (e.g., loss of contrast, saturation) 7. Sacroiliac Joints 4. Contrast 8. Pelvis and Hip 5. Spatial Resolution 9. Hystersalpingography Chapter 1 Preparation for Review 11

2. Thorax and Abdomen Procedures (21 or electronic booklet published by the ARRT to apply to questions) take the radiography certification exam. Read everything in the handbook! You should pay close attention to the A. Thorax ARRT Rules and Regulations and the Standards of Eth- 1. Chest ics and Code of Ethics. Although your program director 2. Ribs may highlight and discuss certain portions of the booklet, 3. Sternum you are responsible for understanding everything it con- 4. Soft Tissue Neck tains. This may be the most important exam you will have B. Abdomen and GI Studies taken so far in your career, so be sure to read the materials 1. Abdomen provided. 2. Esophagus After you read the entire booklet, it is important to fill out 3. Swallowing Dysfunction Study the application, providing all of the information requested. 4. Upper GI Series, Single or Double Contrast Be sure to print legibly and to fill in all information and 5. Small Bowel Series dates accurately. Pay close attention to the photo require- 6. Contrast Enema, Single or Double Contrast ments. You can submit the application up to 3 months 7. Surgical Cholangiography before your anticipated graduation date. 8. ERCP After you have signed the application and your program C. Urological Studies director has signed it, insert the document along with a 1. Cystography check or money order for the application fee into the enve- 2. Cystourethrography lope provided with the application. It is important that you 3. Intravenous Urography mail the envelope yourself. Do not include it in a large enve- 4. Retrograde Urography lope with applications from other members of your class, and do not trust anyone else to mail the application for you. 3. Extremity Procedures (25 questions) Be sure to send your application as certified mail and to request a return receipt. Although this costs slightly more A. Upper Extremities than regular mail, you will receive verification that your 1. Fingers application has been delivered. 2. Hand Several weeks after receipt of your application, the 3. Wrist ARRT will send you exam information and test center 4. Forearm admission instructions. When you receive the admission 5. Elbow information, you should immediately check it to verify the 6. Humerus exam window dates, the exam to be taken, and the personal 7. Shoulder identification on the form. If any of this information is 8. Scapula incorrect or has changed, or if you fail to receive this mail- 9. Clavicle ing after an appropriate period, it is your responsibility to 10. Acromioclavicular Joints contact the ARRT office immediately at (651) 687-0048. B. Lower Extremities Carefully read the process for making an appointment 1. Toes with the test center. Once you have received these docu- 2. Foot ments, put them in a safe place until the day of the exam. 3. Calcaneus You must have completed all of the educational require- 4. Ankle ments of your program to take the ARRT exam; this may 5. Tibia/Fibula be particularly significant if your program requires you 6. Knee/Patella to make up missed time after graduation. If you need to 7. Femur make up missed time, you will have to fulfill this require- 8. Long Bone Measurement ment before taking the exam. Because an associate degree C. Other is required, you must also satisfy all general education 1. Bone Age coursework requirements before being eligible to take 2. Bone Survey (e.g., metastatic, child abuse) the exam. If you are enrolled in a 4-year program, the 3. Arthrography same general education coursework requirement applies. Near your date of graduation, your program director will receive a form from ARRT indicating you have applied to Exam Procedure take the exam and will use the online verification process Application Process to verify you have completed the educational program and are eligible to take the exam. This includes verifica- At the appropriate point in your educational program, tion you have completed all required clinical and didactic your program director will provide you with a printed competencies. 12 PART 1 Review and Study Guide

Test-Taking Skills advance of the test has been discussed previously. Don’t wait until the day before or the day of the exam to get your Do not fear the winds of adversity. Remember, a kite rises paperwork in order. Allowing several days to accomplish against the wind rather than with it. these tasks will ensure that you are prepared for any emergency that arises. Physically and Mentally Preparing for the In preparing your body to take the exam, the basic rule Exam Day of thumb is to treat exam day much as you would any other day. This phase of your preparation should begin the Although most of your preparation for the exam centers on evening before the test. Intake of alcohol or large amounts reviewing your coursework, physical and mental prepara- of food should be avoided. You should get approximately tion must be taken into account as well. The question of the same amount of sleep as usual, waking at your usual how long before the exam date you discontinue your review time. has no definite answer. It is an individual decision, based On the day of the exam, depending on the time of your on how lengthy and thorough a review you have done and appointment, use the time before the test to enhance your how comfortable you are with the material. Consulting mental and physical readiness. Start the day by eating a sub- your instructors or study-skill professionals to clarify your stantial and healthy breakfast. Although you should do this specific needs will prove helpful in answering this question. every day, it is particularly important on test day. As the A brief discussion of the points involved may assist you in hour of the exam nears, you may feel less like eating. A light deciding how long to study. snack is a good idea, but avoid high-sugar snacks so that If you are the type of student who conducts a well- you do not experience a drop in blood sugar as you go in to thought-out, carefully planned review of all of the material, take the exam. as suggested in this chapter, it is reasonable to expect that If you have an exercise regimen that you follow daily, fol- studying will taper off within 2 to 3 weeks before the exam. low it on the test day as well. Exercise helps relieve stress and If you use this review book effectively and cover all of the anxiety for many people. You will probably find that trips content areas over a period of at least 6 months, you should to the restroom increase in number on the test day. This is a be well prepared for the exam and can draw your review to normal physiologic response to the stress associated with the a close several weeks before exam day. anticipation of a major event. If you have not allowed yourself sufficient time to Is such physical preparation really necessary? Why should review and are attempting to compress your studying into you be attentive to this aspect of test taking? With all of the a few weeks, you may wish to keep on reviewing until time and effort expended during your education in medical a date closer to the exam. Be aware that anxiety, which radiography and during the review process, you want to be will tend to increase as the exam approaches, may inter- certain that fatigue and physical stress do not impede your fere with learning and recalling even the most basic infor- ability to take the exam. mation as you continue to review. Also, if you have not Your instructors probably gave you a series of review learned the material over a certain period, there is little exams in the last few months of the program, and you will that you can learn in the last few weeks. Trying to cram have used the online exams that accompany this text. These for the exam is futile. If you have waited too long to begin will have helped you to assess your strengths and weaknesses studying, limit your review to the key points in all of the in the various subject areas. Another reason for these prac- major subject areas. tice exams was to help you become accustomed to sitting As you prepare mentally for the day of the test, realize for 3 or 4 hours while taking an exam. It is important not that apprehension about the exam may surface in unex- to let the physical aspect of test taking hamper your ability pected ways. It is not unusual for students to report hav- to pass the exam. ing strange dreams about the exam. The content of these The writing of this book is grounded in more than 40 dreams may involve driving for hours but never reaching years of experience preparing students to take the ARRT the test center or starting the exam, falling asleep, and wak- exam. Attention to the details in this section will help relieve ing up with only 5 minutes left and nearly 200 questions your anxiety about the exam and allow you to focus on the to answer. This is a normal response to your anticipation more important aspects of reviewing and taking the exam. of a major event. It may also serve as a motivator to continue reviewing and preparing for the exam. You may wish Materials Needed for the Exam to share your dream experiences with other students in your class. You will come to realize that most of them are having You should take very few items with you to the exam center. this response and that it is perfectly normal. No papers, books, calculators, purses, cell phones, or food Another important aspect of preparation for the exam or drink of any kind may be taken into the testing room. involves your physical readiness, which means having The items you should bring include your admission ticket, gathered all of the materials you will need for the test and all required photos, and identification materials required by having prepared your body physically to take an exam of the ARRT. If you wish to use a calculator during the exam, this type. Having the appropriate materials ready well in it will be provided by the test center. Chapter 1 Preparation for Review 13

Environmental conditions of the test center can vary. so you may be assured that you will not be penalized on the The exam room may be warmer or cooler than you would exam because you did not use a certain textbook. prefer. If being too cool is a concern for you, consider Accurate reading is one of the most important skills taking a sweater with you. A good way to prepare for a needed to pass the exam, so read each question carefully. less-than-ideal situation is to study and take practice exams Comprehension of what is being asked is crucial. Do not under different conditions. By doing so, you will be able attempt to read more into the question than is printed. Do to adapt more easily to the variations in temperature and not assume that it is a “trick” question. The exam questions to the room arrangements you may face when you take the are carefully written and well constructed. There should be ARRT exam. nothing on the test that you have not seen before in your Careful reading of ARRT materials will ensure that you studies and during your review. Be careful not to read the have everything you need for the exam. Addressing these question the way you want it to be asked. Take the question issues well ahead of time will free your mind for the more at face value. important task—passing the exam. Questions on the ARRT exam are not all A-B-C-D multiple-choice questions. Questions may be asked using Strategies for Taking the Exam one of several different formats. A valuable resource at http://www.arrt.org is the Item Writing Manual, which Everyone has a preferred system for taking a lengthy, mostly describes the various question formats you may encounter multiple-choice format exam. If you have a method that on the exam. Examples of question formats follow. has worked well in the past, continue to use it. If you seem to lose focus when taking such a test, however, consider Used on ARRT Exams Not Used on ARRT Exams the following suggestions for structuring your approach to Direct question, multiple True-false this exam. choice Just getting started may be difficult for some individuals Incomplete statement Matching and cause them to experience discomfort. Many graduates have reported that they were uneasy when beginning the Exhibits (e.g., radiographs, Comparison test. This is usually the result of the apprehension and stress tables, illustrations, graphs) surrounding this important event. Such an initial response Hot spots or videos Short answer and essay should not be viewed as abnormal, and you can be assured Multiselect items Other (fill-in-the-blank, none of that several of your peers are feeling that same discomfort. Sorted list items the above, all of the above) If this occurs, close your eyes, breathe deeply several times, Combined response and start again. Unless you have severe test anxiety or failed to review and prepare carefully ahead of time, you will be ready to begin answering the questions. There are 200 test items on the exam, plus approxi- The most commonly used format is called the direct ques- mately 20 additional unscored pilot questions. You will have tion. Here you are asked a question and are provided with 3½ hours to answer all of the questions. Additional time is either three or four choices, as follows: allotted to complete a tutorial before beginning the exam Which of the following refers to the grayscale present on and a survey after the exam. Be sure to take the tutorial at a radiographic image? the start and provide feedback to the ARRT at the end of a. intensity the exam. Questions are asked randomly, not by category. b. contrast Most test items include the stem, or question, and the set of c. spatial resolution possible answers. The stem will ask a question; only one of d. brightness the possible answers will be correct. The other choices are Theincomplete statement format simply gives a statement called distracters. Distracters are choices designed to make to complete, as follows: you think they are the correct answer. They often consist of The degree of blackening seen on a radiographic image is the most common incorrect responses. Each question has referred to as radiographic: only one correct answer. a. intensity The technologists who construct the exam attempt to b. contrast include only items for which there is a broad consensus c. spatial resolution regarding the correct response. Questions about specific d. brightness departmental routines and information drawn from only Another format, one you will definitely encounter, is one textbook are not used. Information that is proprietary called an exhibit question. It is a question or series of ques- in nature (i.e., specific to a manufacturer or supplier) is tions referring to a diagram, radiograph, table, chart, or avoided. Several sources are consulted when questions for drawing. On the ARRT exam, 10% or more of the ques- the exam are screened, and only the information common tions use an image or illustration of some kind. Numerous to several sources is used. The ARRT does not officially questions can be asked about exhibits, including using the endorse any textbooks for screening or writing test items, computer mouse to click on a spot or region of the exhibit 14 PART 1 Review and Study Guide

to identify a piece of information. Questions using exhib- questions are commonly used on exams. The certification its are included in the online tests accompanying this text. exam is nothing to fear if you review and prepare properly. Examples of exhibits that may be used are: Be sure to consider the suggestions and strategies presented • Videos here and those identified by your instructors. If you have • Medical images practiced and studied and prepared your strategy, the exam • Anatomic illustrations will be just another quiz. • Positioning photographs or diagrams • Drawings or photographs of equipment and instrumen- Exam Results tation • Models of scientific principles or processes (e.g., x-rays On completion of the test, you will receive your prelimi- interacting with a molecule, dose-response curves) nary exam result on the screen. The result will include a • Tables or graphs with technical factors, technique charts, preliminary scaled score and pass/fail status. Remember that equipment specifications, results of QC tests a scaled score of at least 75 is required to pass the exam. This In another example, you may see a list of four to eight on-screen indication of your score still does not provide evi- options that you are required to place in a correct sequence, dence of certification, and you may not yet legally use the such as the steps involved in opening a sterile tray. These are credentials “R.T.(R)” after your name. called ordering questions. This is done by using the com- Certification becomes official when you receive your puter mouse to drag and drop the answers into a table in ARRT-approved scores and credentials in the mail. Watch their proper order. Questions using ordering are included in for the envelope from the ARRT to arrive. You may also the online tests accompanying this text. wish to visit the “Check certification and registration status” Another format may present you with a question and a link at http://www.arrt.org (click “Employers and Regula- list of several answers from which you will choose all of the tors”) to verify whether or not your name has been added to correct answers. You will receive credit for a correct answer the list of credentialed radiographers. only if you choose all of the correct answers. For example: Which of the following affects the geometry of the radio- KEY REVIEW POINTS graphic image? (Select two responses.) a. mAs The Certification Exam b. OID c. kVp • Questions on the exam are not confined to A-B-C-D multiple-choice questions; other types of questions may d. SID be used. The correct answers would be choices b and d. The com- • Carefully read and safely fileall materials regarding the puter will explain how to indicate your choices. Questions exam provided to you by your instructor and the ARRT. using this format are included in the online tests accompa- • Taper off reviewing as the test day nears. nying this text. • Apprehension about the exam is normal; share your experiences with others. Be aware the Registry is always researching other ques- • Assemble materials needed for test day well ahead tion formats and may insert them into your exam as pilot of time; learn the route to the test center a few days questions being tested for future use. before to be certain of its location. Regardless of the test item format used, after you read the • Maintain usual diet and exercise for test day; avoid question and all of the choices, the first answer you choose large intake of food or alcohol. • Be aware of test item formats used by the Registry: usually is correct. Be careful not to begin second-guessing direct question, incomplete statement, negatively worded, your choice of an answer. Do not watch for patterns of combined response, and exhibit. answers. For example, resist choosing A just because you • Read all test questions and answer choices carefully. haven’t used it in a while, and do not be surprised if a certain answer choice is used for several consecutive questions. Also, all types of question formats may involve clinical scenarios. There is no guessing penalty on the exam, so if you have You’re on Your Way! no idea what the answer is, guess; however, have a strategy, even when guessing. Do not choose an answer with terms that Using this first chapter as a planner, you are now ready to are unfamiliar to you. Students sometimes reason that such a work toward one of the crowning achievements of your edu- choice must be the answer because they have never heard of it cational career. Do all that is expected, and use your time before. Most often, this is not the case. Make an educated guess and talents wisely. Do not allow external distractions to send by ruling out answers you are sure are wrong. Then choose you off course. It is time to plan and work for what is yet to from among the items containing familiar terminology. come—passing the radiography exam and moving on to the Becoming familiar with the types of items that may be next phase of your career. You have numerous human and used will help you anticipate what the exam will be like material resources available to assist you, one of which you and will assist you in studying and preparing. A variety of are reading. Use them all and go for it! Success is a journey, question types are used in this book. Most of these types of not a destination. 2 Patient Care

BASIC PATIENT CARE TERMINOLOGY Verbal communication speaking using clear, concise language Medical asepsis microorganisms have been eliminated as understood by the patient much as possible Nonverbal communication communicating with facial expres- Surgical asepsis complete removal of all organisms from sions, eye contact, or body motions equipment and environment Diversity factors that distinguish humans from one another, Standard precautions first tier of transmission-based isolation including age, gender, race or ethnicity, sexual preference, precautions; uses barriers to prevent contact with blood, all traditional versus nontraditional families, nuclear versus body fluids, nonintact skin, and mucous membranes when extended families, marital status, socioeconomic back- there is a chance that infection could be transmitted ground, political beliefs, religious beliefs, geographic origin Airborne precautions particulate respirator required for indi- or residence, generation, physical or mental disability viduals entering a patient’s room Patient education providing the patient with information Droplet precautions mask required for persons coming in close regarding the procedure being performed, other imaging contact with a patient procedures, or other medical center services Contact precautions gloves and gown required for individuals Torts personal injury law coming in contact with a patient Assault action that causes fear or apprehension in the patient Direct contact transmission infected person touches suscep- Battery inappropriate touching or harm done to the patient tible host False imprisonment unjustified restraint Indirect contact transmission inanimate object containing Invasion of privacy violation of any aspect of patient pathogenic organisms is placed in contact with a susceptible confidentiality person Libel written defamation of character Airborne transmission droplets and dust Slander spoken defamation of character Droplet transmission primarily transmission by coughs, Negligence unintentionally omitting reasonable care sneezes, or other methods of spraying onto a nearby host Respondeat superior an employer is responsible for the Common vehicle transmission primarily transmission by con- employee’s actions taminated items such as food, water, medications, devices, Res ipsa loquitur cause of the negligence is obvious and equipment Implied consent assumes the patient would approve of care if Vector-borne transmission an animal contains and transmits conscious an infectious organism to humans Informed consent patient provides consent after being fully Handwashing most effective method to prevent the spread of informed of need, risks, and alternatives infection Patient bill of rights establishes rights for patients regarding Infection control barriers gloves, protective clothing, masks, diagnosis, treatment, privacy, prognosis, and alternatives eye protection Health Insurance Portability and Accountability Act Temperature normal adult oral temperature is 98° F to 99° F (HIPAA) establishes legal regulations regarding confidential- Pulse normal adult pulse is 60 beats per minute ity of patient records Tachycardia heart rate more than 100 beats per minute Do not resuscitate order (DNR) no code Bradycardia heart rate less than 60 beats per minute Advance directive document used by patient to provide direc- Respiration normal adult rate is 12 to 16 breaths per minute tives regarding medical care before becoming incapacitated Blood pressure normal adult blood pressure is 120/80 mm Hg Durable power of attorney patient provides for another per- Sphygmomanometer device used to measure blood pressure son (personal representative) to make decisions regarding Systolic pressure measurement of the pumping action of the medical care if the patient is unable to communicate heart Patient history provides information for the radiographer Diastolic pressure measurement of the heart at rest about the extent of a patient’s injury and the range of Oxygen administration usual oxygen flow rate is 3 L to 5 L per motion the patient can tolerate minute

15 16 PART 1 Review and Study Guide

Suction unit used to maintain patient’s airway Positive contrast agent iodine or barium Cardiac arrest cessation of heart function Aqueous iodine compound water-soluble sterile contrast Crash cart used in cardiac arrest; contains medications, airways, agent sphygmomanometers, stethoscopes, defibrillators, cardiac Iodinated ionic contrast agents salts of organic iodine com- monitors pounds; composed of positively and negatively charged ions Respiratory arrest cessation of breathing Iodinated nonionic contrast agents agents that do not ionize Shock failure of circulation in which blood pressure is inadequate into separate positive and negative charges to oxygenate tissues and remove by-products of metabolism Anaphylactic reactions flushing, hives, nausea Hypovolemic shock follows loss of a large amount of blood or Cardiovascular reactions hypotension, tachycardia, cardiac plasma arrest Septic shock occurs when toxins produced during massive Psychogenic factors may be caused by patient anxiety infection cause a dramatic decrease in blood pressure Hypodermic needle gauge unit of measurement that indicates Neurogenic shock causes blood to pool in peripheral vessels diameter; the larger the gauge, the smaller the diameter of Cardiogenic shock secondary to cardiac failure or other inter- the needle opening ference with heart function Intravenous (IV) catheter combination unit with a needle Allergic shock (anaphylaxis) allergic reaction to foreign pro- inside a flexible plastic catheter teins after injection of an iodinated contrast agent Biohazardous materials—possible routes of entry inhala- Trauma serious and potentially life-threatening injuries tion, swallowing, absorption through the skin or mucous Ventilators mechanical respirators attached to tracheostomies membranes Nasogastric (NG) tube tube inserted through the nose and Material safety data sheets (MSDS) provide direction for down the esophagus into the stomach handling precautions, safe use of the product, cleanup and Chest tube tube placed to remove fluid or air from the pleural disposal of biohazardous materials space PPE personal protective equipment Negative contrast agent most commonly used negative con- OSHA Occupational Safety and Health Administration trast agent is air CDC Centers for Disease Control and Prevention

Communication with the Patient 4. Nonverbal communication, including eye contact, must be respectful of the patient’s age and ethnicity A. Importance of clear communication 5. The radiographer must be a good listener 1. Establishes a respectful and professional relationship D. Diversity in medical imaging with the patient 1. The radiographer must be aware of the extensive 2. Provides an accurate explanation of the examination diversity of patients 3. Helps the patient feel more comfortable to ask questions 2. Respect for diversity is vital in the performance of 4. Shows respect for the patient medical imaging 5. Demonstrates a professional demeanor on the part of 3. Diversity may include any of, or any combination of, the radiographer the following factors: B. Verbal communication a. Age 1. Verbal communication must be clear and distinct b. Gender 2. Terms used must be in a language the patient can c. Race or ethnicity understand d. Sexual preference 3. Care must be taken that a “difficult day” for the e. Traditional versus nontraditional families radiographer does not enter the tone of verbal com- f. Nuclear versus extended families munication with the patient; that is, the radiographer g. Marital status should always be aware of the tone of voice being h. Socioeconomic background used to communicate i. Political beliefs 4. Verbal communication implies that the radiographer j. Religious beliefs should also possess excellent listening skills to inter- k. Geographic origin or residence pret properly what the patient is saying l. Generation C. Nonverbal communication m. Physical or mental disability 1. The radiographer must be continually aware of how facial n. Language expressions or other body motions may be interpreted 4. The radiographer must be fully aware that the patient 2. Words may be saying one thing, but nonverbal population is composed of infinite diversity in infi- actions may be communicating an entirely different nite combinations attitude toward the patient E. Patient education 3. The use of touch must be appropriate and never open 1. Patient education is part of the radiographer’s scope to uncertainty or miscommunication of practice Chapter 2 Patient Care 17

2. The radiographer must be able to explain to the 2. Battery patient, in words the patient understands, the imag- a. Unlawful touching or touching without consent ing procedure being performed b. Harm resulting from physical contact with 3. Patient education includes answering questions from radiographer the patient regarding the procedure c. May also include radiographing the wrong patient 4. The radiographer should also be able to answer basic or the wrong body part or performing radiography questions regarding other imaging modalities, such as against a patient’s will the following: 3. False imprisonment a. Mammography a. Unjustified restraint of a person b. Nuclear medicine b. Care must be taken when using restraint straps c. Angiography or having other individuals assist with holding a d. CT patient still e. MRI 4. Invasion of privacy f. Bone densitometry a. Violation of confidentiality of information g. Ultrasound b. Unnecessarily or improperly exposing the patient’s 5. The radiographer should be able to answer basic ques- body tions, or provide directions to the patient, regarding c. Unnecessarily or improperly touching a patient’s other medical center services, such as the following: body a. Social services d. Photographing patients without their permission b. Discharge planning 5. Libel: Written information that results in defamation c. Pastoral care of character or loss of reputation d. Rehabilitation 6. Slander: Orally spreading false information that results e. Business office in defamation of character or loss of reputation f. Other medical departments 7. Manipulation of electronic data that is ethically wrong and legally questionable: KEY REVIEW POINTS a. using the wrong processing algorithm b. altering the exposure indicator Communication with the Patient c. cropping/masking anatomy postexposure • Clear and comfortable communication—establishing C. Unintentional misconduct (negligence) this with the patient is of paramount importance 1. Neglect or omission of reasonable care • Verbal communication—must be clear and in a 2. Based on doctrine of the reasonably prudent person language the patient understands 3. Reasonably prudent person doctrine: Based on how a • Nonverbal communication—conveys the radiographer’s reasonable person with similar education and experi- attitude and demeanor • Diversity—the radiographer must be aware of age, ence would perform under similar circumstances gender, race or ethnicity, sexual preference, traditional 4. Gross negligence: Acts that show reckless disregard for versus nontraditional families, nuclear versus extended life or limb families, marital status, socioeconomic background, 5. Contributory negligence: Instance in which the injured political beliefs, religious beliefs, geographic origin or person is a contributing party to the injury residence, generation, physical or mental disability • Patient education—the radiographer must understand the D. Four conditions needed to establish malpractice role of patient educator and be prepared to answer basic 1. Establishment of standard of care questions regarding mammography, nuclear medicine, 2. Demonstration that standard of care was violated by angiography, CT, MRI, bone densitometry, ultrasound, the radiographer social services, discharge planning, pastoral care, 3. Demonstration that loss or injury was caused by rehabilitation, business office, other medical departments radiographer who is being sued 4. Demonstration that loss or injury actually occurred and is a result of the negligence Medicolegal Aspects of Practice E. Respondeat superior 1. “Let the master answer” A. Torts 2. Legal doctrine stating that an employer is held liable Violations of civil law for an employee’s negligent act Also known as personal injury law F. Rule of personal responsibility: Individuals are respon- Injured parties have a right to compensation for injury sible for their own actions B. Intentional misconduct G. Res ipsa loquitur 1. Assault 1. “The thing speaks for itself” a. Patient is apprehensive about being injured 2. Legal doctrine stating that the cause of the negligence b. Imprudent conduct of radiographer that causes fear is obvious (e.g., forceps left inside a patient during in patient is grounds for an allegation of civil assault surgery) 18 PART 1 Review and Study Guide

H. Charting j. Consent to or decline participation in research 1. Using electronic medical record or writing on the studies patient’s chart by radiographer k. Continuity of care and other options for care 2. Varies by institution beyond the hospital 3. Radiographer’s responsibilities in this regard must be l. Be informed of hospital policies and procedures carefully outlined during new employee orientation related to diagnosis and treatment 4. Write clear statements regarding patient’s condi- m. Be informed of all resources available for resolving tion and patient’s reaction to contrast agents; write disputes amount of contrast material injected n. Be informed of charges for services and payment 5. Must be clearly stated on the chart options 6. Information must also include the date and time of 2. Implied consent the occurrence a. Provides for care when patient is unconscious 7. Radiographer must sign chart entries using institu- b. Based on assumption that patient would approve tional protocol care if conscious 8. In case of error, correct electronically or strike over 3. Valid consent once and rewrite correct entry; never erase or obscure a. Also called informed consent erroneous information b. Patient must be mentally competent I. Radiographic images c. Consent must be offered voluntarily 1. Radiographic images are legal documents, whether d. Patient must be adequately informed electronic or on film e. Patient must be of legal age 2. Images must include the following information: f. Requires that radiographer or radiologist care- a. Patient identification fully explain all aspects of procedure and risks b. Anatomic markings, including left and right involved markers g. Requires that explanation be provided in lay terms c. Carefully placed markings on each radiograph the patient understands using lead markers 4. Health Insurance Portability and Accountability Act d. Date of exposure (HIPAA) e. Markings placed on the image following exposure a. Passed by US Congress and enacted under rules may not be legally admissible and regulations of US Department of Health and 3. Retention of images Human Services a. Varies according to state law b. Hospitals must put in place policies and proce- b. Normally maintained for 5 to 7 years after the dures regarding the release of patient information date of the last radiographic examination (mam- c. Patient must provide clear permission for release mograms and black lung images are kept for the of any information to outside parties (e.g., medical, life span of the patient) financial, employment) c. Files on minors are normally retained for 5 to 7 d. Patient must be informed in writing of how the years after the minor reaches age 18 or 21, depend- released information will be used ing on the state of residence e. Patient must be allowed to view and copy records J. Patient’s rights and amend records as needed 1. Patient’s bill of rights from the American Hospital Asso- f. Any history of information sharing must be dis- ciation provides for patient consent or refusal of any closed to the patient procedure; the patient has the right to the following: g. Patient must freely provide consent for informa- a. Respectful care tion to be shared b. Obtain up-to-date and understandable medical h. Patient has the right to restrict sharing of information regarding diagnosis, treatment, and information likely outcomes i. Patient may file a complaint regarding a violation c. Be involved in the decision-making process of HIPAA throughout diagnosis and treatment 5. Do not resuscitate order (DNR) d. Have an advance directive (living will, health care a. Also called no code proxy, durable power of attorney) on file b. May be placed on file when the quality of life e. Privacy in all aspects of diagnosis and treatment has seriously declined or the patient’s condition f. Complete confidentiality is terminal g. View medical records of the case c. Agreement is between the physician and the h. Expect that a hospital will respond to a request for patient (or the designated person holding power needed care and services of attorney if the patient is incompetent) i. Be informed of business or educational relation- d. The agreement or appropriate notation is made on ships that may affect treatment and care the patient’s chart Chapter 2 Patient Care 19

6. Advance directive computed tomography, magnetic resonance imaging, a. Patient provides directives regarding medical care quality management, sonography, bone densitometry, before becoming incapacitated vascular sonography, cardiac-interventional radiography, b. Patient may do this so that directions are in place vascular-interventional radiography, breast sonography, and should the patient be unable to communicate radiologist assistant. The Standards of Ethics are intended to be consistent with the Mission Statement of ARRT, and to wishes regarding care promote the goals set forth in the Mission Statement. c. Copies should be provided to physician, attorney, family member, and medical record Rules of Ethics The Rules of Ethics form the second part of the Standards 7. Durable power of attorney of Ethics. They are mandatory standards of minimally a. Patient provides for another person (personal rep- acceptable professional conduct for all Certificate Holders resentative) to make decisions regarding medical and Candidates. Certification and Registration are methods care if the patient is unable to communicate of assuring the medical community and the public that b. This personal representative may sign informed an individual is qualified to practice within the profession. Because the public relies on certificates and registrations consent forms for the patient issued by ARRT, it is essential that Certificate Holders and c. The patient and personal representative should Candidates act consistently with these Rules of Ethics. These communicate clearly ahead of time the patient’s Rules of Ethics are intended to promote the protection, safety, thoughts regarding extraordinary methods of and comfort of patients. The Rules of Ethics are enforceable. treatment and end-of-life wishes Certificate Holders and Candidates engaging in any of the following conduct or activities, or who permit the occurrence K. American Registry of Radiologic Technologists (ARRT) of the following conduct or activities with respect to them, Mission and Standards of Ethics have violated the Rules of Ethics and are subject to sanctions 1. The accompanying box contains the ARRT Mission as described hereunder: Statement, Standards of Ethics Preamble, and Rules 1. Employing fraud or deceit in procuring or attempting of Ethics to procure, maintain, renew, or obtain or reinstate certification and registration as issued by ARRT; 2. The Standards of Ethics promote the goals of the employment in radiologic technology; or a state permit, Mission Statement license, or registration certificate to practice radiologic 3. The Standards of Ethics are comprised of the Code of technology. This includes altering in any respect any Ethics (not listed here) and the Rules of Ethics document issued by the ARRT or any state or federal 4. The Code of Ethics serves as a guide for what radio- agency, or by indicating in writing certification and registration with the ARRT when that is not the case. logic technologists aspire to become as professionals 2. Subverting or attempting to subvert ARRT’s 5. The Rules of Ethics are mandatory, enforceable, and examination process, and/or the structured self- carry sanctions for violations assessments that are part of the Continuing 6. The Standards of Ethics also include a section address- Qualifications Requirements (CQR) process. Conduct ing administrative procedures, not included here (for that subverts or attempts to subvert ARRT’s examination and/or CQR assessment process includes, details, visit http://www.arrt.org) but is not limited to: (i) disclosing examination and/or CQR assessment information using language that is substantially THE AMERICAN REGISTRY OF RADIOLOGIC similar to that used in questions and/or answers TECHNOLOGISTS (ARRT) MISSION from ARRT examinations and/or CQR assessments STATEMENT AND RULES OF ETHICS (NOT when such information is gained as a direct result INCLUDING CODE OF ETHICS) of having been an examinee or a participant in a Mission CQR assessment or having communicated with an examinee or a CQR participant; this includes, but is not limited to, disclosures to students in The mission of The American Registry of Radiologic educational programs, graduates of educational Technologists is to promote high standards of patient care programs, educators, anyone else involved by recognizing qualified individuals in medical imaging, in the preparation of Candidates to sit for the interventional procedures, and radiation therapy. examinations, or CQR participants; and/or (ii) soliciting and/or receiving examination and/or CQR The ARRT Standards of Ethics assessment information that uses language that Preamble is substantially similar to that used in questions The Standards of Ethics of the American Registry of Radiologic and/or answers on ARRT examinations or CQR Technologists® (ARRT) shall apply solely to persons holding assessments from an examinee, or a CQR certificates from ARRT that are either currently certified participant, whether requested or not; and/or and registered by ARRT or that were formerly certified and (iii) copying, publishing, reconstructing (whether registered by ARRT (collectively, “Certificate Holders”), and by memory or otherwise), reproducing or to persons applying for certification and registration by ARRT transmitting any portion of examination and/or to become Certificate Holders (“Candidates”). Radiologic CQR assessment materials by any means, verbal Technology is an umbrella term that is inclusive of the disciplines or written, electronic or mechanical, without the of radiography, nuclear medicine technology, radiation therapy, prior express written permission of ARRT, or using cardiovascular-interventional radiography, mammography, professional, paid or repeat examination takers

Continued 20 PART 1 Review and Study Guide

THE AMERICAN REGISTRY OF RADIOLOGIC (iii) military courts-martial related to any offense TECHNOLOGISTS (ARRT) MISSION identified in these Rules of Ethics. STATEMENT AND RULES OF ETHICS (NOT 4. Violating a rule adopted by a state or federal regulatory INCLUDING CODE OF ETHICS)—Cont’d authority or certification board resulting in the individual’s professional license, permit, registration, or certification being denied, revoked, suspended, placed on probation or a consent agreement or order, and/or CQR assessment participants, or any other voluntarily surrendered, subjected to any conditions, or individual for the purpose of reconstructing any failing to report to ARRT any of the violations or actions portion of examination and/or CQR assessment identified in this Rule. materials; and/or 5. Performing procedures which the individual is not iv) using or purporting to use any portion of competent to perform through appropriate training examination and/or CQR assessment materials that and/or education or experience unless assisted or were obtained improperly or without authorization personally supervised by someone who is competent for the purpose of instructing or preparing any (through training and/or education or experience). Candidate for examination or participant for CQR 6. Engaging in unprofessional conduct, including, but not assessment; and/or limited to: (v) selling or offering to sell, buying or offering to buy, (i) a departure from or failure to conform to applicable or distributing or offering to distribute any portion federal, state, or local governmental rules regarding of examination and/or CQR assessment materials radiologic technology practice or scope of practice; without authorization; and/or or, if no such rule exists, to the minimal standards (vi) removing or attempting to remove examination of acceptable and prevailing radiologic technology and/or CQR assessment materials from an practice; examination or assessment room; and/or (ii) any radiologic technology practice that may create (vii) having unauthorized possession of any portion unnecessary danger to a patient’s life, health, or of, or information concerning, a future, current, safety. or previously administered examination or CQR Actual injury to a patient or the public need not be assessment of ARRT; and/or established under this clause. (viii) disclosing what purports to be, or what you claim 7. Delegating or accepting the delegation of a radiologic to be, or under all circumstances is likely to be technology function or any other prescribed understood by the recipient as, any portion of, healthcare function when the delegation or or “inside” information concerning any portion acceptance could reasonably be expected to create of, a future, current, or previously administered an unnecessary danger to a patient’s life, health, examination or CQR assessment of ARRT; and/or or safety. Actual injury to a patient need not be (ix) communicating with another individual during established under this clause. administration of the examination or CQR 8. Actual or potential inability to practice radiologic assessment for the purpose of giving or receiving technology with reasonable skill and safety to patients help in answering examination or CQR assessment by reason of illness; use of alcohol, drugs, chemicals, questions, copying another Candidate’s, or CQR or any other material; or as a result of any mental or participant’s answers, permitting another Candidate physical condition. or a CQR participant to copy one’s answers, or 9. Adjudication as mentally incompetent, mentally ill, possessing unauthorized materials including, but chemically dependent, or dangerous to the public, by not limited to, notes; and/or a court of competent jurisdiction. (x) impersonating a Candidate, or a CQR participant, 10. Engaging in any unethical conduct, including, but or permitting an impersonator to take or attempt to not limited to, conduct likely to deceive, defraud, or take the examination or CQR assessment on one’s harm the public; or demonstrating a willful or careless own behalf; and/or disregard for the health, welfare, or safety of a patient. (xi) using any other means that potentially alters the Actual injury need not be established under this results of the examination or CQR assessment clause. such that the results may not accurately represent 11. Engaging in conduct with a patient that is sexual the professional knowledge base of a Candidate, or or may reasonably be interpreted by the patient as a CQR participant. sexual, or in any verbal behavior that is seductive or 3. Convictions, criminal proceedings, or military courts- sexually demeaning to a patient; or engaging in sexual martial as described below: exploitation of a patient or former patient. This also (i) conviction of a crime, including a felony, a gross applies to any unwanted sexual behavior, verbal or misdemeanor, or a misdemeanor, with the sole otherwise. exception of speeding and parking violations. All 12. Revealing a privileged communication from or alcohol and/or drug-related violations must be relating to a former or current patient, except when reported; and/or otherwise required or permitted by law, or viewing, (ii) criminal proceeding where a finding or verdict of using, releasing, or otherwise failing to adequately guilt is made or returned, but the adjudication of protect the security or privacy of confidential patient guilt is either withheld, deferred, or not entered or information. the sentence is suspended or stayed; or a criminal 13. Knowingly engaging or assisting any person to proceeding where the individual enters an Alford engage in, or otherwise participate in, abusive or plea, a plea of guilty or nolo contendere (no contest); fraudulent billing practices, including violations of or where the individual enters into a pre-trial diversion federal Medicare and Medicaid laws or state medical activity; or assistance laws. Chapter 2 Patient Care 21

THE AMERICAN REGISTRY OF RADIOLOGIC KEY REVIEW POINTS TECHNOLOGISTS (ARRT) MISSION STATEMENT AND RULES OF ETHICS (NOT Medicolegal Aspects of Practice INCLUDING CODE OF ETHICS)—Cont’d • Torts: Violations of civil law; personal injury law • Intentional misconduct: Assault (patient is apprehensive about being injured) 14. Improper management of patient records, including • Intentional misconduct: Battery (unlawful touching failure to maintain adequate patient records or to furnish or touching without consent); may also include a patient record or report required by law; or making, radiographing the wrong patient or wrong body part or causing, or permitting anyone to make false, deceptive, performing radiography against a patient’s will or misleading entry in any patient record. • Intentional misconduct: False imprisonment (unjustified 15. Knowingly assisting, advising, or allowing a person restraint of a person) without a current and appropriate state permit, license, • Intentional misconduct: Invasion of privacy (violation of registration, or an ARRT-registered certificate to engage confidentiality of information; unnecessary or improper in the practice of radiologic technology, in a jurisdiction exposure or touching of the patient’s body) that mandates such requirements. • Intentional misconduct: Libel (written information that 16. Violating a state or federal narcotics or controlled- results in defamation of character or loss of reputation) substance law. • Intentional misconduct: Slander (orally spreading false 17. Knowingly providing false or misleading information that is information that results in defamation of character or directly related to the care of a former or current patient. loss of reputation) 18. Subverting, attempting to subvert, or aiding others • Unintentional misconduct: Negligence (neglect or to subvert or attempt to subvert ARRT’s Continuing omission of reasonable care) Education (CE) Requirements, and/or ARRT’s Continuing • Unintentional misconduct: Based on doctrine of the Qualifications Requirements (CQR). Conduct that reasonably prudent person subverts or attempts to subvert ARRT’s CE or CQR • Reasonably prudent person doctrine: How a reasonable Requirements includes, but is not limited to: person with similar education and experience would (i) providing false, inaccurate, altered, or deceptive perform under similar circumstances information related to CE or CQR activities to ARRT • Gross negligence: Acts that demonstrate reckless or an ARRT-recognized recordkeeper; and/or disregard for life or limb (ii) assisting others to provide false, inaccurate, • Four conditions needed to establish malpractice: (1) altered, or deceptive information related to CE or Establishment of standard of care; (2) demonstration CQR activities to ARRT or an ARRT-recognized that standard of care was violated by the radiographer; recordkeeper; and/or (3) demonstration that loss or injury was caused by (iii) conduct that results or could result in a false or radiographer who is being sued; (4) demonstration that deceptive report of CE or CQR completion; and/or loss or injury actually occurred and is a result of the (iv) conduct that in any way compromises the integrity negligence of the CE or CQR Requirements, such as sharing • Respondeat superior (“Let the master answer”): Legal answers to the post-tests or self-learning activities, doctrine stating that an employer is held liable for an providing or using false certificates of participation, employee’s negligent act or verifying credits that were not earned. • Res ipsa loquitur (“The thing speaks for itself”): Legal 19. Subverting or attempting to subvert the ARRT doctrine stating that cause of the negligence is obvious certification and registration processes by: (e.g., forceps left inside a patient during surgery) (i) making a false statement or knowingly providing • Charting: Entering clear statements regarding the false information to ARRT; or patient’s condition, reaction to contrast agents, and (ii) failing to cooperate with any investigation by the ARRT. amount of contrast material injected 20. Engaging in false, fraudulent, deceptive, or misleading • Radiographic images: Legal documents; must include communications to any person regarding the patient identification, anatomic markings (including left individual’s education, training, credentials, experience, and right markers), and date of exposure or qualifications, or the status of the individual’s state • Altering electronic data related to radiographic images permit, license, or registration certificate in radiologic may be legally challenged technology or certificate of registration with ARRT. • Patient’s rights: Patient Bill of Rights provides for 21. Knowing of a violation or a probable violation of any Rule patient’s consent to, or refusal of, any procedure and of Ethics by any Certificate Holder or Candidate and failing access to appropriate medical information; allows for to promptly report in writing the same to the ARRT. advance directive (i) Failing to immediately report to his or her supervisor • Implied consent: Provides for care when patient is information concerning an error made in connection unconscious with imaging, treating, or caring for a patient. For • Valid consent: Patient must be mentally competent; purposes of this rule, errors include any departure consent must be offered voluntarily; patient must from the standard of care that reasonably may be be adequately informed; patient must be of legal considered to be potentially harmful, unethical, age; requires radiographer and radiologist to explain or improper (commission). Errors also include carefully, in lay terms the patient understands, all behavior that is negligent or should have occurred aspects of procedure and risks involved; also called in connection with a patient’s care, but did not informed consent (omission). The duty to report under this rule exists • Health Insurance Portability and Accountability Act whether or not the patient suffered any injury. (HIPAA): Medical facilities must put in place policies and procedures regarding the release of patient information

KEY REVIEW POINTS—Cont'd KEY REVIEW POINTS Medicolegal Aspects of Practice Scheduling of Radiographic Examinations

• Do not resuscitate (DNR) order: May be placed on file • Schedule so that examinations do not interfere with one when the quality of life has seriously declined or the another, with barium studies last patient’s condition is terminal; also called no code • Schedule radiographic examinations not requiring • Advance directive: Patient provides directives regarding contrast agents first medical care before becoming incapacitated • Schedule patients who have been held NPO (nothing • Durable power of attorney: Patient provides for another by mouth) first; schedule pediatric and geriatric patients person (personal representative) to make decisions early; schedule diabetic patients early because of their regarding medical care if the patient is unable to need for insulin communicate • Sequence of examinations: Fiberoptic (endoscopy) • ARRT Standards of Ethics includes Code of Ethics studies; radiography of the urinary tract; radiography (what radiologic technologists aspire to become) and of the biliary system; CT studies before examinations Rules of Ethics (mandatory and enforceable behaviors) involving the use of barium sulfate; lower GI series; upper GI series

Scheduling of Radiographic Examinations Patient Preparation

A. General considerations A. GI system or urinary system 1. Schedule in an appropriate and timely sequence to 1. Low-residue diet (e.g., low fiber) or clear liquid diet ensure patient comfort and fiscal responsibility (e.g., tea, gelatin, bouillon) 2. Sequence so that examinations do not interfere with 2. NPO for 8 to 12 hours before procedure one another 3. Cathartics and enemas are used to cleanse the GI system 3. Schedule barium studies last 4. If scheduled as an outpatient 4. Schedule several examinations in a single day if the a. Patient must clearly understand the routine for patient is able to tolerate them proper preparation 5. Seriously ill or weak patients may be able to tolerate b. Patient should be asked to explain the procedure only one examination per day or must have a rest back to the radiographer to verify understanding between examinations B. All procedures 6. If sedation is used, patient must be given time to 1. Clothing is removed from area to be radiographed recover from sedation before beginning fluoroscopic and replaced by patient gown when appropriate studies 2. All radiopaque objects are removed from area of 7. Thyroid assessment must precede any examinations interest involving iodinated contrast media 8. Schedule radiographic examinations not requiring KEY REVIEW POINTS contrast agents first Patient Preparation 9. Total doses of iodinated contrast media should be calculated if they are to be used in a series of • GI system or urinary system: Low-residue diet; NPO examinations for 8 to 12 hours before the procedure; cathartics and 10. Schedule patients who have been held NPO (noth- enemas used to cleanse GI system; patient must clearly ing by mouth) first understand the routine for proper preparation • All procedures: Clothing removed from area to be 11. Schedule pediatric and elderly patients early radiographed; all radiopaque objects removed from 12. Schedule diabetic patients early because of their area of interest need for insulin B. Sequence of examinations 1. Fiberoptic (endoscopy) studies are conducted first in a series Patient History 2. Radiography of the urinary tract 3. Radiography of the biliary system A. Provides information for the radiographer about the 4. CT studies should be scheduled before examinations extent of the patient’s injury and the range of motion involving the use of barium sulfate the patient can tolerate 5. Lower gastrointestinal (GI) series (check for residual B. Assists the radiologist during interpretation of the contrast material from previous examinations before radiographs proceeding) C. History should begin with the radiographer introducing 6. Upper GI series himself or herself and verifying the patient’s name Chapter 2 Patient Care 23

D. Types of questions asked to obtain a patient’s history F. Place one arm around patient’s shoulder and the other (depending on type and site of injury) arm under the knees 1. How did your injury occur? G. Assist patient to a supine position 2. When did your injury occur? 3. Where is your pain? Transfer from X-Ray Table to Wheelchair 4. Do you have tingling or numbness? 5. Do you have any weakness? A. Check to see that brakes of wheelchair have been applied 6. Were you unconscious after your injury? B. Assist patient to a sitting position 7. Why did your physician order this examination? C. Allow patient to sit up for a short time to regain sense of 8. Have you experienced shortness of breath or been balance coughing? D. Ambulatory patient 9. Have you experienced a fever or heart problems? 1. Assist to a standing position and pivot 10. Have you experienced any nausea, vomiting, or 2. Have patient reach back with both hands and grab diarrhea? arms of wheelchair 11. Have you had previous surgery on this area? 3. Assist patient to sit in the wheelchair 12. Is there any family history of problems in this area? E. Nonambulatory patients 1. Stand facing the patient 2. Reach around patient and place your hands on each KEY REVIEW POINTS scapula Patient History 3. Lift patient upward to a standing position with your knees bent • Purpose: Provides information for the radiographer; 4. Pivot so that the back of the patient’s leg is touching assists the radiologist during interpretation of the images the edge of the wheelchair; ensure the wheels on the • Types of questions asked to obtain a patient’s history: wheelchair are locked How did your injury occur? When did your injury occur? 5. Ease patient down to a sitting position with your Where is your pain? Do you have tingling or numbness? Do you have any weakness? Were you unconscious knees bent after your injury? Why did your physician order this 6. Position foot and leg rests into place examination? Have you experienced shortness of 7. Cover patient’s lap with a sheet breath or been coughing? Have you experienced a fever or heart problems? Have you experienced any nausea, vomiting, or diarrhea? Cart Transfer A. Place cart near and parallel to the x-ray table, and lock wheels Patient Transfer B. Do not attempt patient transfer from cart to x-ray table without assistance A. Check identification bracelet to ensure that correct C. One person supports the neck and shoulders at the head patient is being transferred of the cart; the second person lifts the pelvis and knees; B. Ask patient to state his or her name to double-check if available, other individuals support patient at both identity; ask date of birth as a backup sides C. Explain the transfer procedure to the patient to gain D. Transfer sheet or draw sheet should be used under cooperation and alleviate fear patient; a slide board should be used when available D. The radiographer must always use proper body mechan- E. On signal, all persons involved in transfer move patient ics for patient transfer in one fluid motion to the x-ray table 1. Keep knees slightly bent 2. Keep back straight Patient Comfort 3. Use legs, not back, to perform all lifting A. Taking into account the patient’s physical condition, Transfer from Wheelchair to X-Ray Table carefully position pillows or radiolucent sponges so that they do not interfere with the examination A. Wheelchair is parallel to table B. Evaluate patient’s condition B. Brakes are applied with step stool nearby 1. Ability to breathe C. Using face-to-face method, assist the patient to a stand- 2. Presence of nausea ing position 3. Allow patient to remain partially upright when D. Have patient place one hand on step stool handle, place the possible other hand on your shoulder, and step up onto the stool 4. Special care must be given to older patients, who E. Patient pivots with back against the table into a sitting may have decubitus ulcers or particularly sensitive position on the edge of the table or thin skin 24 PART 1 Review and Study Guide

KEY REVIEW POINTS Standard Precautions Patient Transfer A. First tier of transmission-based isolation precautions B. System that uses barriers to prevent contact with blood, • Check identification bracelet to ensure that correct all body fluids, nonintact skin, and mucous membranes, patient is being transferred • Explain transfer procedure to patient to gain if there is a chance of transmission of infection cooperation and alleviate fear C. Assumes all body fluids are sources of infection • Always use proper body mechanics D. Assumes all patients are infected • Ensure all appropriate brakes are applied E. Guidelines • Make creative use of sheets and helpers when moving 1. Always wear gloves when any chance of being in con- patient tact with body substances exists 2. Protect clothing by wearing a protective gown or plastic apron, if a chance of coming in contact with body substances exists 3. Masks or eye protection must be worn if a chance of Infection Control body-substances splashing exists Routes of Transmission 4. Handwashing is the most effective method to prevent the spread of infection A. General Concepts 5. Uncapped needle syringe units and all sharps must be 1. Cycle of infection = All factors involved in the spread discarded in biohazard containers of disease 6. If any contact is made with body substances, the a. Infectious organism: Pathogen entire area contacted must be washed completely b. Reservoir of infection: Place where organisms can with bleach thrive 7. Contaminated articles must be disposed of properly c. Portal of exit: Any avenue available to exit the 8. Needles should never be recapped but should be body placed with the syringe in a sharps container d. Susceptible host: Person at risk for infection 9. Protective masks or mouthpieces should be used when e. Portal of entry: Any avenue available to enter the performing cardiopulmonary resuscitation (CPR), if body providing breaths in addition to chest compression. f. Mode of transportation: Route taken by pathogens from reservoir to susceptible host Medical Asepsis 2. Healthcare Acquired Infections (HAIs) a. Also called nosocomial infections A. Includes proper hand hygiene b. Approximately 2 million persons acquire HAI per 1. Use alcohol-based hand sanitizer for 15 seconds year 2. Conventional handwashing (duration): 30 to 60 c. CDC estimates 90,000 annual deaths because of seconds HAIs a. Adjust water temperature d. Most common route of infection involves urinary b. Wet hands catheter c. Lather antimicrobial soap into hands and fingers B. Direct Contact Transmission: for at least 20 seconds 1. infected person touches susceptible host, allowing the d. Rinse clear infectious organisms to come in contact with suscep- e. Dry thoroughly tible tissues f. Turn off faucet with paper towel when handles are 2. Fomite: An object that has been in contact with present pathogens comes in contact with susceptible 3. No wearing of artificial nails tissues B. Microorganisms have been eliminated as much as possible C. Airborne transmission: Droplets and dust that are C. Water and chemicals are used for the disinfection able to remain suspended in air for extended periods of time Surgical Asepsis D. Droplet transmission: Transmitted primarily by coughs, sneezes, or other methods of spraying onto a nearby A. Complete removal of all organisms from equipment and host the environment in which patient care is conducted E. Common vehicle transmission: Transmitted primarily by B. Includes complete sterilization of equipment and appro- contaminated items such as food, water, medications, priate skin preparation devices, and equipment 1. Chemical sterilization: Soaking objects in germicidal F. Vector-borne transmission: Animal or insect contains and solution transmits infectious organism to humans 2. Boiling: Sterilization with moist heat Chapter 2 Patient Care 25

3. Dry heat: Placing objects in an oven at temperatures Types of Transmission-Based Precautions greater than 329° F 4. Gas sterilization: Items are exposed to a mixture of A. Airborne precautions—in addition to standard gases, which do not harm the materials precautions 5. Autoclaving: Steam sterilization under pressure; most 1. Wash hands before patient care convenient way to sterilize materials 2. Workers and visitors entering patient’s room must wear particulate respirators Sterile Technique 3. Wash hands after patient care B. Droplet precautions—in addition to standard precautions A. Steps to follow in the opening of sterile packs 1. Wash hands before patient care 1. Check expiration date 2. Surgical masks required for persons coming in close 2. Place pack on a clean surface contact with patient 3. Break seal and open pack 3. Wash hands after patient care 4. Unfold the first corner of the pack away from you C. Contact precautions—in addition to standard precautions 5. Unfold both sides 1. Wash hands before patient care 6. Pull front portion of the wrap toward you and drop 2. gloves, and gowns are indicated for individuals com- it ing in contact with patient 7. Never touch the inner surface 3. Wash hands after patient care 8. If there is an inner wrap, open it using the same Isolation Technique method 9. Separately wrapped sterile items may be added to Mobile Radiography the sterile field by opening the pack and allowing A. Requires two people, designated “dirty” and “clean”; the the items to drop onto the sterile field “clean” radiographer handles the portable x-ray machine 10. Never allow the container to touch the sterile field and controls while the first “dirty” radiographer touches B. Pouring liquids into containers in a sterile field only the patient; both must wash hands before and after 1. Carefully determine the contents of the container the procedure 2. Pour a small amount into a waste receptacle to cleanse B. If protective cap is indicated, it should be put on and all the lip of the bottle hair should be tucked inside 3. Pour the medium into the receptacle, being careful C. Mask should be put on next, completely covering the not to touch the sterile field in the process nose and mouth C. Sterile objects or fields touched by unsterile objects or D. Gown should be put on and tied securely at the back and persons are immediately contaminated neck D. Avoid reaching across sterile fields E. Gloves should be put on and pulled over the end of the E. If you suspect that an object is contaminated, assume sleeve of the gown that it is contaminated F. Radiographic IR should be placed in a protective plastic F. Always assume that damp items are contaminated cover G. Do not invade the space between a physician and the G. Enter patient’s room and follow all isolation guidelines sterile field that have been posted H. Never abandon a sterile field; it must be under direct H. After the radiographic exposure is made observation at all times I. Remove IR from the vicinity of the patient I. Never turn your back on a sterile field J. Open the end of the protective covering J. Remember: Only from your waist up and in front is K. “Clean” radiographer handling the equipment should sterile remove cassette from the open end of the cover L. When leaving the patient’s isolation room, carefully Gloving remove attire and leave it in room 1. Untie waist belt of protective gown A. Wash hands thoroughly 2. Remove gloves B. Open outer package containing gloves a. Pull off one glove by grasping the cuff and invert- C. Open inner package, exposing gloves ing it as it is pulled off D. Approach glove from open end, and touch only inner b. Remove second glove by inserting clean fingers surface with opposite hand inside the cuff and inverting it as it is removed E. Put on glove, touching only the folded cuff 3. Untie neck and back strings from gown F. Pick up other glove with gloved hand under the cuff 4. Remove mask by using strings only G. Place second glove on other hand, and unfold cuff 5. Remove gown by holding it away from the body as it H. Carefully unfold cuff on both gloves is removed I. Always keep hands in front of the body without touch- 6. Carefully wash hands ing body covering or placing hands under arms 7. Use paper towels to touch faucet handles 26 PART 1 Review and Study Guide

M. After portable x-ray unit is moved safely outside the • Protective masks or mouthpieces: Wear when room, it should be cleaned thoroughly before it is performing CPR returned to the radiology department • Handwashing: Most effective method to prevent spread of infection Patients in Radiology Departments • Uncapped needle syringe units and all sharps: Must be discarded in biohazard containers A. Identify precaution and follow guidelines • Medical asepsis: Microorganisms have been eliminated B. Isolation patients should never spend time waiting in the as much as possible hallway • Surgical asepsis: Complete removal of all organisms C. Carefully cover x-ray table with a sheet • Chemical sterilization: Soaking of objects in germicidal D. Work in pairs so that only one radiographer is in con- solution • Boiling: Sterilization with moist heat tact with the patient (dirty) while the other radiogra- • Dry heat: Placing objects in an oven at temperatures pher manipulates the equipment (clean); both wash greater than 329° F hands • Gas sterilization: Items are exposed to a mixture of E. Carefully cover patient with protective sheets and gases, which do not harm the materials blankets when returning patient to the wheelchair or • Autoclaving: Steam sterilization under pressure; most convenient way to sterilize materials cart • Sterile technique: Several steps required to maintain F. All contaminated materials must be placed in an appro- integrity of sterile field; review each step and be able to priate discard bag place them in order G. Carefully clean off x-ray table and any other equipment • Gloving: Several steps required for proper gloving; with which the patient came in contact review each step and be able to place them in order H. Remove gloves and carefully wash hands • Transmission-based precautions: Airborne precautions; droplet precautions; contact precautions Patients with Neutropenia • Isolation technique during mobile radiography: Specific A. Have a decrease in white blood cell count steps are required; know each step and the order in B. Neutropenia may be caused by chemotherapy, immuno- which steps occur • Isolation technique in the imaging department: Specific therapy, bone marrow transplant steps are required; know each step and the order in which C. Radiographers caring for patients with neutropenia must steps occur carefully follow hospital protocol so as not to transmit something to the patient that they cannot resist D. Some institutions continue to use a similar form of isolation called 'reverse isolation' Assessment of Changing Patient KEY REVIEW POINTS Conditions

Infection Control A. Visual observation of patient B. Changes in skin color to cyanotic or waxen pallor • Routes of transmission: May be direct or indirect • Direct contact: Infected person touches susceptible C. Patient verbalizations of discomfort or dizziness host, allowing infectious organisms to come in contact D. Cyanosis of lips or nail beds with susceptible tissues E. Patient is cool and diaphoretic to touch • Indirect contact: Object containing pathogenic organisms is placed in contact with susceptible person • Airborne transmission: Droplets and dust Vital Signs • Droplet transmission: Transmitted primarily by coughs, sneezes, or other methods of spraying onto a nearby A. Temperature: Normal oral temperature is 98° F to host 99° F • Common vehicle transmission: Transmitted primarily by B. Pulse contaminated items such as food, water, medications, 1. Taken at radial or carotid artery devices, and equipment • Vector-borne transmission: Animal contains and 2. Tachycardia: More than 100 beats per minute transmits an infectious organism to humans 3. Bradycardia: Less than 60 beats per minute • Standard precautions: System that uses barriers to C. Respiration: Normal respiratory rate is 12 to 16 breaths prevent contact with blood, all body fluids, nonintact per minute skin, and mucous membranes of all individuals and D. Blood pressure susceptible persons; assumes all body fluids are sources of infection; assumes all patients are infected 1. Measured with sphygmomanometer • Gloves: Should always be worn 2. Systolic pressure: Measurement of pumping action of • Protective gown: Wear to protect clothing the heart • Masks and eye protection: Must be worn if there is a 3. Diastolic pressure: Measurement of the heart at rest chance that body substances will be splashed 4. Diastolic pressure greater than 90 mm Hg indicates increasing level of hypertension Chapter 2 Patient Care 27

5. Diastolic pressure less than 50 mm Hg gives some 2. Hypovolemic shock: Follows loss of large amount of indication of shock blood or plasma 6. Always expressed as systolic pressure over diastolic 3. Septic shock: Occurs when toxins produced during pressure (e.g., 120/80 mm Hg) massive infection cause a dramatic decrease in blood pressure Medical Emergencies 4. Neurogenic shock: Causes blood to pool in peripheral vessels A. Oxygen administration 5. Cardiogenic shock: Results from cardiac failure or 1. Generally administered via a mask or nasal cannula other interference with heart function 2. Usual oxygen flow rate is 3 to 5 L/minute 6. Allergic shock (anaphylaxis) 3. Care must be taken while radiographing patients who . a Allergic reaction to foreign proteins after are on portable oxygen support; avoid pinching or injections kinking oxygen tubing . b Marked by extremely low pressure, dyspnea, and 4. Radiographers must know how to operate oxygen possible death tanks or wall oxygen outlets so that they can adminis- . c May follow injection of iodinated contrast ter oxygen to a patient in the event of an emergency media B. Suction unit 7. Symptoms of shock 1. Used to maintain patient’s airway a. Restlessness; apprehension 2. Must be used any time the airway becomes obstructed . b Accelerated pulse by fluids c. Pale skin 3. If the radiographer is working alone and the patient’s d. Weakness airway needs suctioning, the radiographer should call e. Alteration in ability to think for help before beginning procedure . f Cool, clammy skin C. Cardiac arrest g. Systolic blood pressure less than 30 mm Hg 1. Cessation of heart function 8. Radiographer’s response to shock 2. Specific routine for announcing cardiac arrest must a. Stop procedure be followed . b Place patient in recumbent (Trendelenburg) posi- . 3 Emergency medical assistance must be called tion immediately c. Immediately obtain help, calling a code if neces- 4. CPR must begin immediately sary 5. Radiographer must be familiar with location and d. Determine blood pressure contents of crash cart e. Administer oxygen a. Medications . f Accurately document the time and occurrence of . b Airways each symptom c. Sphygmomanometers .F Trauma d. Stethoscopes 1. Serious, potentially life-threatening injuries e. Defibrillators 2. Be careful to do no additional harm to the patient . f Cardiac monitors 3. Be prepared to work with other health care profes- D. Respiratory arrest sionals present in the radiography room 1. Cessation of breathing 4. Be prepared to perform a cross-table lateral cervical 2. Possible causes of respiratory arrest spine examination as soon as possible or transport a. Upper respiratory tract swelling to CT . b Failure of the central nervous system 5. Regardless of which area of the body is to be radio- c. Choking graphed, assume that a serious internal injury is 3. Tracheolaryngeal edema present a. Tracheolaryngeal edema may follow injection of 6. Patient is at one of four levels of consciousness iodinated contrast material a. Alert and conscious . b May necessitate an emergency tracheotomy . b Drowsy c. Radiographer should know location of tracheot- c. Unconscious but reactive to stimuli omy tray d. Comatose 4. Respiratory arrest caused by central nervous system 7. Carefully observe the condition of the patient when failure necessitates calling a respiratory arrest code first brought to the radiography room 5. Respiratory arrest secondary to choking necessitates 8. Note any changes in patient’s condition during the use of suction or the Heimlich maneuver course of radiographic procedures E. Shock 9. Trauma patients should not be left alone under any 1. Failure of circulation in which blood pressure is inad- circumstances equate to oxygenate tissues and remove by-products 10. Until otherwise informed by a physician, assume of metabolism the presence of serious spinal injuries 28 PART 1 Review and Study Guide

11. Slight movement of a patient who has spinal inju- 3. Bag attached to urinary catheters must always be kept ries may result in paralysis or death below the level of the bladder 12. Immobilization devices, such as cervical collars or 4. Allowing urine to flow retrograde into the urethra splints, must never be removed unless permission is and bladder can cause urinary tract infections granted by a physician a. Urinary tract infections are the number one cause 13. Be prepared to alter routine positions and projec- of nosocomial infections (infections acquired in tions because of the inability to move the anatomic the hospital) part F. Oxygen 14. Adjust radiographic technique to compensate for 1. Oxygen should not be removed during radiographic the presence of splints, spine boards, and other examinations (but care should be taken to remove immobilization devices tubing away from anatomy being radiographed) 15. Work carefully with patients who have wounds, 2. Oxygen may be removed only with a physician’s order making certain to wear gloves 3. Care should be taken to avoid pinching the tubing 16. Observe condition of wounds when patient is brought for radiography, and immediately notify emergency department personnel of any changes in KEY REVIEW POINTS wounds, including fresh bleeding 17. Patients who have severe burns require protective Assessment of Changing Patient Conditions isolation a. Patients who have severe burns experience either The radiographer should be able to observe changes in no sensation at all or extreme pain patient condition and understand the ramifications of each. Review those listed in the outline. b. Care must be exercised when working with burn • Temperature: Normal oral temperature is 98° F to 99° F patients under either condition • Pulse: Normal is around 60 beats per minute; greater than 100 beats per minute indicates tachycardia; less than 60 beats per minute indicates bradycardia Patient Monitoring and Support Equipment • Respiration: Normal rate of respiration is 12 to 16 breaths per minute A. Ventilators • Blood pressure: Always expressed as systolic pressure 1. Mechanical respirators attached to tracheostomies over diastolic pressure (e.g., 120/80 mm Hg) 2. Patient who has a ventilator has been intubated (a • Systolic pressure: Measurement of the pumping action tube inserted into the trachea) of the heart 3. Care must be taken not to dislodge tubing connected • Diastolic pressure: Measurement of the heart at rest • Oxygen administration: Generally administered using to tracheostomy mask or nasal cannula; usual oxygen flow rate is 3 to 5 B. Nasogastric (NG) tubes L/minute 1. Tube inserted through the nose and down the esoph- • Suction unit: Used to maintain patient’s airway agus into the stomach • Cardiac arrest: Cessation of heart function; CPR must 2. Used to feed the patient or to conduct gastric suction begin immediately • Crash cart: Medications, airways, sphygmomanometers, 3. Care must be taken by the radiographer not to pull stethoscopes, defibrillators, cardiac monitors on the NG tube while moving patient or performing • Respiratory arrest: Cessation of breathing; CPR must the examination begin immediately C. Chest tube • Respiratory arrest caused by choking: Necessitates the 1. In place to remove fluid or air from pleural space use of suction or the Heimlich maneuver • Shock: Failure of circulation in which blood pressure 2. May be connected to a suction device is inadequate to oxygenate tissues and remove 3. Radiographer must be careful not to disturb the chest by-products of metabolism tube or suction devices or bottles to which tube may • Hypovolemic shock: Follows loss of large amount of be attached blood or plasma 4. Bottle must never be raised above chest level • Septic shock: Occurs when toxins produced during massive infection cause a dramatic decrease in blood 5. Tubing must not be pinched pressure D. Venous catheters • Neurogenic shock: Causes blood to pool in peripheral 1. May be kept in place for patients requiring long-term vessels chemotherapy or nutrition • Cardiogenic shock: Caused by cardiac failure or other 2. Must not be disturbed or pulled in any way interference with heart function • Allergic shock (anaphylaxis): Allergic reaction to foreign E. Urinary catheters (Foley and suprapubic) proteins after injections 1. Care must be taken during transfer and radiography • Symptoms of shock: Restlessness; apprehension; of patients who have urinary catheters in place accelerated pulse; pale skin; weakness; alteration 2. Urinary catheter tubing must not be bent, pinched, in ability to think; cool, clammy skin; systolic blood or caught on other equipment and pulled out of the pressure less than 30 mm Hg bladder Chapter 2 Patient Care 29

• Radiographer’s response to shock: Stop procedure, D. Aqueous iodine compounds place patient in a recumbent (Trendelenburg) position, 1. Used for contrast studies of GI tract immediately obtain help, call a code if necessary, 2. Used when barium could be a surgical contaminant determine blood pressure, and administer oxygen a. Perforated ulcers • Trauma: Serious, potentially life-threatening injuries; do b. Ruptured appendix no additional harm to the patient • Four levels of consciousness: Alert and conscious, 3. Aqueous iodine compounds may also be used in drowsy, unconscious but reactive to stimuli, comatose patients at high risk for impactions • Ventilators: Mechanical respirators attached to 4. These compounds may cause significant dehydration tracheostomies E. Iodinated contrast media • NG tube: Tube inserted through the nose and down the 1. Ionic contrast agents esophagus into the stomach • Chest tube: In place to remove fluid or air from the a. Salts of organic iodine compounds pleural space b. Composed of positively and negatively charged • Venous catheters: May be kept in place for patients ions requiring long-term chemotherapy or nutrition 2. Nonionic contrast agents • Urinary catheters (Foley and suprapubic): Do not a. Similar to ionic contrast agents bend, pinch, or catch tubing; bag attached to urinary catheters must always be kept below the level of the b. Do not ionize into separate positive and negative bladder charges, which affords their primary advantage • Urinary tract infections: Number one cause of health over ionic contrast agents care-acquired infections c. Provide far lower incidence of contrast agent reactions 3. Contraindications to use of iodinated contrast media Contrast Media a. Previous sensitivity to contrast agents b. Known sensitivity to iodine A. Negative contrast agent 4. Both ionic and nonionic contrast agents are iodinated 1. Most commonly used agent is air (i.e., both contain various concentrations of iodine— 2. Requires fewer x-rays and produces a higher density nonionic does not mean noniodinated) on the image Pharmacology 3. Air may be used in combination with a positive contrast agent on double-contrast studies History and Patient Care Preceding Injection 4. Most common examination performed using a nega- of Iodinated Contrast Media tive contrast agent is a routine chest radiograph A. Determine history of allergies or previous hypersensitiv- B. Positive contrast agents ity to contrast media 1. Examples B. Determine extent of patient’s medical problems, includ- a. Iodine (atomic number 53) ing medications being taken b. Barium (atomic number 56) C. Review possible reactions to contrast medium being 2. Relatively high atomic numbers used; determine the presence of contraindications a. Result in greater attenuation of x-rays D. Verify pertinent laboratory values (blood urea nitrogen b. Provide lower density on radiograph (BUN), creatinine, and glomerular filtration rate) per c. Provide an increase in contrast between structure department and contrast agent protocol to be visualized and surrounding structures E. Verify appropriate dosage related to patient weight and C. Barium age 1. Administered to patient in the form of barium sul- F. Know the location of all emergency equipment fate, an inert salt G. Obtain informed consent from patient per department 2. For upper GI series and esophagogram, barium is protocol most palatable when mixed with very cold water H. Carefully observe and evaluate the patient, noting color 3. For barium enema, barium powder is mixed with of skin, tone and pitch of voice, and presence of appre- water at a temperature of approximately 100° F hension or anxiety, so that changes from these baseline 4. For some studies of esophagus, barium sulfate paste, observations may be noted after injection which is much thicker and more difficult to swallow, may be administered Patient Care Following Injection of Iodinated 5. Barium tends to absorb water Contrast Media 6. Patients must be given careful instructions regarding A. Continue conversation with patient fluid intake after barium studies so that the barium 1. Encourage patient to speak does not cause an impaction 2. Laryngeal swelling as a contrast agent reaction first 7. Barium sulfate escaping into the peritoneal cavity can manifests as a change in the tone and pitch of the cause peritonitis patient’s voice 30 PART 1 Review and Study Guide

B. Continue to observe the patient for early signs of urti- KEY REVIEW POINTS caria, profuse sweating, or extreme anxiety C. If patient becomes overanxious, take patient’s pulse to Contrast Media determine whether tachycardia is present D. If patient becomes faint, immediately check respirations, • Negative contrast agent: Air • Positive contrast agents: Iodine and barium pulse, and blood pressure, and observe for signs of cya- • Barium: As barium sulfate; in cold water for upper GI, nosis 100° F for lower GI E. Be aware of the location of a physician in the event of an • Aqueous iodine compounds: Used for contrast studies emergency, such as a contrast agent reaction of GI tract when barium could prove to be a surgical F. Remain with the patient (except when at the control contaminant (perforated ulcers, ruptured appendix) • Iodinated ionic contrast media: Contain positively and panel to make exposures) negatively charged ions 1. Patient should never be left alone after injection or at • Iodinated nonionic contrast agents: Do not ionize into any time during the procedure separate positive and negative charges, which is their 2. Although most contrast media reactions are notice- primary advantage over ionic contrast agents; far lower able and may even be violent, others are more dif- incidence of contrast agent reactions • Contrast agent reaction: Anaphylactic (flushing, ficult to observe hives, nausea); cardiovascular reaction (hypotension, a. A patient who appears to be resting comfort- tachycardia, cardiac arrest); psychogenic factors (may ably or sleeping may have experienced cardiac be caused by patient anxiety) arrest • Other symptoms of contrast agent reactions: Nausea 3. Summon help immediately on observing the onset of and vomiting, sneezing, sensation of heat, itching, hoarseness (or change in pitch of voice during a contrast agent reaction conversation), coughing, urticaria, dyspnea, loss of a. Although a calm response is required to avoid consciousness, convulsions, cardiac arrest, paralysis, alarming the patient, urgency is important because any change in level of orientation a mild contrast agent reaction may quickly acceler- • Determine patient history of allergies or previous ate into a more serious reaction hypersensitivity to contrast media and extent of medical problems Contrast Media Complications and • Continue talking with and observing patient after injection; be prepared to recognize any signs of a Reactions reaction A. Overdose: May occur in infants or adults who have renal, cardiac, or hepatic failure B. Anaphylactic reactions: Flushing, hives, nausea C. Cardiovascular reactions: Hypotension, tachycardia, car- Venipuncture diac arrest D. Psychogenic factors: May be caused by patient anxiety or A. Use of hypodermic needle suggested by the possible reactions described during the 1. May be used for small injections informed consent process 2. Described by gauge E. Other symptoms of contrast agent reactions a. Unit of measurement that indicates diameter 1. Nausea and vomiting b. The larger the gauge, the smaller the diameter of 2. Sneezing the needle opening 3. Sensation of heat c. Higher gauge needles are useful for intravenous 4. Itching (IV) injection of contrast agents because they 5. Hoarseness (or change in pitch of voice during make a smaller hole and limit bleeding at the site conversation) d. Higher gauge needles limit the rate at which con- 6. Coughing trast material may be injected and consequently 7. Urticaria limit the size of the bolus that may be injected 8. Dyspnea B. IV catheter 9. Loss of consciousness 1. Combination unit with a needle inside a flexible plas- 10. Convulsions tic catheter 11. Cardiac arrest 2. Combination unit is inserted into the vein, needle 12. Paralysis first 13. Any change in level of orientation 3. Once in place, catheter is pushed in over the needle F. Complications may occur at site of injection 4. Afterward, needle is withdrawn 1. Local irritation may occur if contrast material 5. Catheter may be connected to syringe containing extravasates contrast medium 2. Phlebitis may occur in the vein in which contrast 6. Entire system is more flexible than a hypodermic material was injected needle or butterfly Chapter 2 Patient Care 31

7. Also allows attachment to IV tubing leading to bag or bottle, which can be used in the event of a serious contrast agent reaction C. Winged infusion set (butterfly) 1. Has a needle and small plastic “butterfly wings” pro- jecting from either side 2. Wings may be taped to patient’s skin once needle is in place 3. Short length of tubing connects the butterfly to the syringe so needle does not move if syringe is moved D. Procedure for performing venipuncture 1. Wash hands 2. Always wear gloves 3. Secure tourniquet in place 4. Select vein 5. Thoroughly cleanse the skin using departmental protocol 6. Push medication or contrast agent through the nee- • Figure 2-1 Biohazardous waste container and symbol. dle prior to inserting into vein so as to avoid inject- ing air 2. Possible routes of entry 7. Insert needle into vein a. Inhalation 8. Observe blood return into catheter, plastic tubing, b. Swallowing or syringe, depending on equipment used; remove c. Absorption through the skin or mucous tourniquet membranes 9. Begin injection immediately 3. Material safety data sheets (MSDS) must be available, 10. If using hypodermic needle, remove needle at con- and radiographers should be familiar with their conclusion of injection tent and warnings a. Place small piece of gauze or alcohol wipe on 4. MSDS provide direction for the following: puncture site, and bend patient’s arm a. Handling precautions b. Dispose of needle and syringe correctly; never b. Safe use of the product recap c. Cleanup and disposal 11. If using catheter, continue until all contrast medium 5. Guidelines for handling chemicals has been injected, then disconnect syringe, and a. Use only if container is clearly labeled observe site for swelling b. Read container label several times before using the 12. If using butterfly, tape wings to patient’s skin if indi- contents to be certain of what is being handled cated c. Handle carefully to prevent contact with skin, 13. Do not discard vial of injected agent until examina- eyes, and mucous membranes tion is completed and patient has left the area d. Wear personal protective equipment (PPE) e. Use chemicals only as directed f. Never mix chemicals unless compatibility can be KEY REVIEW POINTS verified Venipuncture g. Store chemicals only as directed on label h. Never pour toxic chemicals down the drain; this Specific steps and knowledge are required when performing includes irritating or flammable materials venipuncture; know each step and the order in which it i. Clean up spills immediately according to written occurs. Review the equipment used and the procedure. procedures j. After contact with the skin, rinse immediately with cool water for at least 5 minutes Hazardous Materials k. After contact with eyes, rinse for at least 15 minutes l. Always notify the supervisor on duty, and follow Handling and Disposal of Biohazardous guidelines for medical follow-up and incident reports Materials (Figure 2-1) B. Infectious waste 1. Anything that has the potential to transmit disease A. General chemicals 2. Handle using US Centers for Disease Control 1. Chemicals may cause harm if taken into the body by and Prevention (CDC) guidelines for standard any route precautions 32 PART 1 Review and Study Guide

6. Gloves must always be worn in the following activities: a. Handling used needles and syringes b. Handling bandages and dressing c. Assisting patients who use urinals or bedpans 7. Needles and syringes must be disposed of in special sharps containers (Figure 2-2) 8. Needles should not be recapped 9. Used bandages and dressings must be placed into red plastic biohazard bags and sealed 10. Bedpans and urinals must be emptied immediately and rinsed

KEY REVIEW POINTS Hazardous Materials

• Route of entry: May enter the body by any route— inhalation, swallowing, absorption through skin or mucous membranes • MSDS: Radiographers should be familiar with their content and warnings • Handling chemicals: Know all guidelines and be able to explain each step • Infectious waste: Handle using CDC guidelines for • Figure 2-2 Puncture-proof container for needle and syringe standard precautions; place in containers or bags disposal. properly labeled with type of waste therein • Gloves: Must always be worn when handling used needles and syringes; handling bandages and dressing; assisting patients who use urinals or bedpans 3. Place in containers or bags properly labeled with the • Needles and syringes: Must be disposed of in special type of waste therein (e.g., linens, used sharps, dis- sharps containers; must not be recapped posable items) • Used bandages and dressings: Must be placed into 4. Know the facility’s procedures for handling, con- waterproof bags and sealed • Bedpans and urinals: Must be emptied immediately and tainment, and disposal of all infectious waste rinsed 5. Exposure to infectious waste must be reported for medical follow-up and incident reports

Review Questions 1. Routes of entry of toxic chemicals may include: c. Just before lunch a. Swallowing and inhalation d. In any way that helps the work flow b. Inhalation only 5. Patients with diabetes should be scheduled: c. Absorption through skin or mucous membranes a. Late in the day to give them time to build their d. Inhalation, swallowing, or absorption through strength skin or mucous membranes b. Only after they have had their insulin 2. Written instructions for handling of biohazardous c. As early in the day as possible materials, safe use of the product, and cleanup and d. Immediately after a full breakfast disposal directions are called: 6. Endoscopic procedures should be scheduled: a. Package inserts a. After ingestion of barium for increased contrast b. HIPAA b. First in a series of procedures c. MSDS c. After a series of procedures so as to verify the d. Biohazardous warning systems diagnosis 3. Older patients should be scheduled: d. Only by the endoscopy department a. Late in the day to give them time to build their 7. What describes torts? strength a. Violations of criminal law b. For one examination at a time b. Considered part of personal injury law c. As early in the day as possible c. Provide for compensation for injury d. Only when no one else is in the department d. Violations of civil law that are part of personal 4. Patients who have been NPO should be scheduled: injury law and provide for compensation for injury a. Last 8. Which of the following may be considered as an b. First example of battery? Chapter 2 Patient Care 33

a. Violating HIPAA c. Libel b. Radiographing the wrong patient or body part d. Res ipsa loquitur c. Verbally abusing a patient 17. Which of the following statements are true concern- d. Criticizing a physician’s order in front of a patient ing valid (informed) consent? 9. Assault means: 1. Patient must be of legal age a. Threatening the patient or causing the patient to 2. Patient must be given a brochure describing the be apprehensive risks of the procedure in lay terms b. Striking the patient 3. Consent must be offered voluntarily c. Touching the patient without consent 4. Patient must be mentally competent d. Performing radiography against the patient’s will 5. Patient must completely understand all aspects of 10. Which of the following is an example of invasion of the procedure privacy? a. 1, 3, 4 a. Radiographing the wrong patient b. 1, 2, 3, 4, 5 b. Unjustified restraint of patient c. 1, 2, 3, 4 c. Improperly exposing the patient’s body d. 1, 2, 3, 5 d. Radiographing the wrong body part 18. Patient transfers from cart to x-ray table and back to 11. Unintentional misconduct is also called: cart should be performed: a. Negligence a. By the radiographer alone if the patient is b. An accident ambulatory c. Libel b. By two or more radiographers to ensure patient d. Slander and radiographer safety 12. The concept of the reasonably prudent person is c. By the radiographer alone if the department is interpreted as: short staffed a. How a reasonable jury member would perform d. By the radiographer alone so as not to frighten the the act patient b. How a professional who has similar education, 19. A patient history should be taken by the radiographer: training, and experience would perform the act a. To assist the radiographer in understanding the c. How a prudent attorney would interpret the act patient’s injury and to assist the radiologist with d. How a reasonable and prudent judge would rule interpretation of the images on the act b. To verify patient name and form of payment 13. Respondeat superior means: c. Only on patients from the ED a. “The thing speaks for itself” d. Only in the absence of the patient’s chart b. A radiographer has no need to carry malpractice 20. Direct contact allows an infectious organism to insurance move: c. The reasonable and prudent person should make a. From the susceptible host directly to the infected the decision person d. “Let the master answer” b. From the infected person directly to the suscep- 14. Gross negligence is: tible host a. A case that includes the injured person as a con- c. In either direction tributing party to the injury 21. MSDS provide directions for: b. Loss of life or limb a. Housekeeping only c. An act that shows reckless disregard for life or limb b. Engineering only d. Found in criminal cases only c. Radiology only 15. Which of the following conditions must be met to d. All persons exposed to hazardous materials prove malpractice? 22. If the radiographer touches hazardous chemicals, a. The injury actually occurred and is a result of what must be done first? negligence a. Rinse immediately with warm water b. The standard of care was violated by the person b. Rinse immediately with cool water for at least 5 being sued minutes c. The injury was caused by the person being sued c. Rinse immediately with cool water for at least 15 and is a result of negligence minutes d. The standard of care was violated and the injury d. Rinse with the warmest water that can be actually occurred and was caused by the defendant tolerated and was a result of negligence 23. Vectors may be: 16. A case involving obvious negligence would be defined a. Insects by the doctrine of: b. Persons a. Respondeat superior c. Plants b. Slander d. Objects 34 PART 1 Review and Study Guide

24. Common vehicle transmission involves: c. Must be evaluated by infection control a. The spread of infection in crowded forms of public d. Must be reported to risk management transportation, such as jet aircrafts, subways, and 34. Hands should be washed: trains a. At least five times during each shift to help stop b. Food, water, medications, and equipment the spread of infections c. Animals b. Before and after contact with each patient and d. Plants before touching equipment 25. Airborne transmission of infection may occur as a c. Every hour regardless of patient contact result of contact with: d. Both with and without gloves a. Bird droppings, acid rain, or air pollution 35. The process of eliminating as many organisms as pos- b. Droplets and dust sible by the use of water and chemical disinfectants is c. Animals called: d. Other humans a. Surgical asepsis 26. Indirect contact involves: b. Sterilization a. Coughs or sneezes c. Medical asepsis b. An object containing pathogenic organisms d. Boiling c. Plants and animals 36. The process of eliminating all organisms from the d. Other humans environment by gas sterilization, use of germicides, or 27. A system that emphasizes the placement of barriers use of dry heat is called: between the health care worker and the patient is called: a. Surgical asepsis a. Universal precautions b. Sterilization b. Standard precautions c. Medical asepsis c. Universal safety d. Autoclaving d. Infection barriers 37. When putting on gloves for a procedure, which of the 28. The placement of barriers between the health care following should occur first? worker and the patient assumes that: a. Carefully open glove package, and avoid touching a. There is always a contagion present outside of gloves b. No one wants to be touched b. Wash hands c. Every patient should be in isolation c. Place glove package in center of sterile field in d. Every health care worker is carrying something preparation for the procedure contagious d. Put on one glove immediately so that one hand is 29. The most effective method used to prevent the spread protected and the other is free of infection is: 38. After a radiographer is gowned and gloved for a pro- a. Wearing of gloves cedure, hands may not be placed: b. Wearing of gowns a. Anywhere on the body because the gown and c. Distance gloves are sterile d. Handwashing b. Anywhere on the front or sides of the gown 30. Because barium enemas increase the possibility of c. Anywhere on the table containing the sterile field contact between body substances and clothing, the d. Under the arms or on the sides or back of the radiographer should always wear: gown a. Disposable gowns or surgical scrubs 39. A radiographer who is assisting with a sterile proce- b. Head covering dure but is not gloved and gowned: c. Shoe covering a. Should stand between the physician and the sterile d. A regular hospital uniform field 31. A radiographer should wear eye protection: b. Should carefully place all utensils needed in the a. Any time blood may be present center of the sterile field by dropping them after b. Any time an injection is being made removing them from their packages c. Any time there is a possibility of blood splashing c. May briefly come in contact with the sterile field d. With nearly all patients to move utensils around 32. Needles should be recapped after use: d. May not have contact with the sterile field or any- a. Never one who is scrubbed in b. Always 40. What route of transmission involves touching a sus- c. In a nonsterile field ceptible person with a contaminated object (e.g., an d. Only during procedures involving a sterile field IR)? 33. Any area that is touched by body fluids: a. Droplet transmission a. Must be washed completely b. Indirect contact b. Must be covered and isolated for the remainder of c. Direct contact the day d. Airborne transmission Chapter 2 Patient Care 35

41. Which of the following transmission-based precau- 50. The reservoir of infection is located: tions also require the use of standard precautions? a. Anywhere organisms can thrive a. Airborne and droplet precautions b. On all surfaces b. Only contact precautions c. Only on patients in isolation c. Only droplet precautions d. Only on already contaminated surfaces d. Droplet, contact, and airborne precautions 51. Assessment of changing patient conditions includes 42. Which of the following rules must always be followed observing for: regardless of the route of transmission of infection? a. Skin that becomes unusually warm a. Gloves must be worn b. Patient expressions of discomfort or dizziness b. Gowns must be worn c. Lips that become jaundiced c. Patient must not have any direct contact with the d. Skin that becomes diaphoretic, lips and nails that health care worker turn cyanotic, and patient complaints of dizziness d. Handwashing must be performed or discomfort 43. Which of the following does not require the use of 52. The normal adult body temperature taken orally is: gloves? a. 98.6° C 1. Airborne b. 98° C to 99° C 2. Droplet c. 99.6° F 3. Contact d. 98° F to 99° F a. 1 only 53. Which of the following may be ingested by a patient b. 2 only who has been placed on a clear liquid diet? c. 1, 2 1. Bouillon d. 1, 3 2. Gelatin 44. Which of the following requires that all equipment 3. Tea and personnel be carefully covered? a. 1 and 2 only a. Airborne precautions b. 1 and 3 only b. Contact precautions c. 2 and 3 only c. Droplet precautions d. 1, 2, and 3 d. Patients with neutropenia 54. Barium sulfate is classified as a(n): 45. What is used for total protection of the health care a. Dissolvable organic salt worker from every method of transmission possible b. Inert inorganic salt in the work setting? c. Nonionic contrast agent a. Standard precautions d. Iodinated contrast agent b. Airborne precautions 55. A sphygmomanometer is used to: c. Contact precautions a. Hear the heartbeat d. Droplet precautions b. Hear the blood pressure 46. Used bandages and dressings must be placed: c. Measure blood pressure a. Inside contaminated linens so they are not touched d. Measure body temperature b. Into red plastic biohazard bags and sealed 56. A blood pressure of 120/80 mm Hg reveals that: c. Into sharps containers a. The pressure is 120 mm Hg when the heart is d. In a nearby waste container at rest 47. The winged infusion set used for venipuncture is also b. The diastolic pressure is 120 mm Hg known as: c. The systolic pressure is 80 mm Hg a. IV catheter d. The pressure is 80 mm Hg when the heart is at rest b. Hypodermic needle 57. When oxygen is administered, the usual rate is: c. Butterfly a. 3 to 5 lb/minute d. Winged injection set b. 3 to 5 L/hour 48. When performing mobile radiography on a patient in c. 3 to 5 L/minute isolation, which two radiographers are designated? d. 5 to 7 L/minute a. Primary and secondary 58. A mechanical method used to clear the patient’s air- b. Clean and contaminated way is called: c. Technologist and student a. The Heimlich maneuver d. Clean and dirty b. CPR 49. The most common site of health care-acquired infec- c. Suctioning tions (HIA) is: d. NG tube insertion a. Open wound 59. Which of the following contains all the instruments and b. Compound fracture medications necessary for dealing with cardiac arrest? c. Urinary catheter a. Crash cart d. Surgical sutures b. Tackle box 36 PART 1 Review and Study Guide

c. IVP cabinet a. 1, 3, 4 d. Code cabinet b. 1, 2, 3 60. What condition is caused by loss of a large amount of c. 1, 4, 5 blood or plasma? d. 1, 2, 3, 4, 5 a. Anaphylaxis 69. Which of the following is used to feed a patient or b. Cardiogenic shock conduct gastric suction? c. Hypovolemic shock a. Urinary catheter d. Septic shock b. Chest tube 61. What causes blood to pool in peripheral vessels? c. Ventilator a. Anaphylaxis d. NG tube b. Cardiogenic shock 70. Which of the following is used to administer nutri- c. Hypovolemic shock tion or long-term chemotherapy? d. Neurogenic shock a. Urinary catheter 62. What follows an allergic reaction to foreign proteins? b. Chest tube a. Anaphylaxis c. Ventilator b. Cardiogenic shock d. Venous catheter c. Hypovolemic shock 71. What is the site of most nosocomial (health care- d. Septic shock acquired) infections? 63. What is caused by an infection that results in a. Urinary catheter extremely low blood pressure? b. Chest tube a. Anaphylaxis c. NG tube b. Cardiogenic shock d. Venous catheter c. Hypovolemic shock 72. What is another name for a mechanical respirator? d. Septic shock a. Urinary catheter 64. What condition occurs secondary to heart failure or b. Chest tube interference with heart function? c. Ventilator a. Anaphylaxis d. Venous catheter b. Cardiogenic shock 73. The most frequently performed examination using a c. Hypovolemic shock contrast medium is a(n): d. Septic shock a. Small bowel study 65. What condition may occur after injection of an iodin- b. IVP ated contrast agent? c. Barium enema a. Anaphylaxis d. Chest x-ray study b. Cardiogenic shock 74. Which of the following statements are true concern- c. Hypovolemic shock ing positive contrast media? (choose 4) d. Septic shock a. Air is the most commonly used 66. Which of the following is a symptom of shock? b. Aqueous iodine compounds may be used if perfo- a. Accelerated pulse; extremely warm skin rations are suspected b. Accelerated pulse; cool, clammy, pale skin c. Barium should be mixed with cold water for retro- c. Systolic pressure less than 50 mm Hg grade administration d. Accelerated pulse; cool, clammy, pale skin; systolic d. Nonionic contrast media are ideal for injection blood pressure less than 30 mm Hg because they do not contain iodine, reducing the 67. What should the radiographer do first when it is sus- risk of reactions pected a patient is going into shock? e. Barium is an inert substance a. Call for assistance f. Aqueous iodine compounds may cause serious b. Place patient in Trendelenburg position dehydration c. Take patient’s blood pressure to confirm shock status g. Barium is a surgical contaminant d. Administer oxygen 75. Which of the following is a legitimate contraindica- 68. Which of the following statements apply when radi- tion to the use of iodinated contrast media? ography is performed on trauma patients? a. Allergy to seafood 1. Work quickly and efficiently b. Known sensitivity to proteins 2. Patient may be left alone if unconscious c. Previous sensitivity to contrast agents 3. Spinal injury may be ruled out if patient is not on d. Allergy to any medications a spine board or wearing a cervical collar 76. A reaction at the site of injection of iodinated contrast 4. Observe for changes in wound dressing while per- media may be caused by: forming radiography a. Extravasation of contrast agent 5. Document in writing changes in patient’s condition b. Allergy to seafood Chapter 2 Patient Care 37

c. Anaphylaxis 1. Secure tourniquet in place d. Allergy to certain medications 2. Thoroughly cleanse the skin 77. Which of the following is a symptom (are symptoms) 3. Wash hands of a contrast agent reaction? 4. Select vein a. Hoarseness and sneezing 5. Put on gloves b. Sneezing only 6. Perform puncture c. Urticaria is the primary symptom 7. Cover wound and compress site d. Hoarseness, sneezing, urticaria, and vomiting 8. Inject contrast agent 78. After injection of iodinated contrast media, the 9. Check wound for swelling radiographer should: 10. Observe blood return a. Leave the patient to rest a. 5, 4, 1, 6, 8, 7 b. Remain with the patient and have a conversation b. 3, 1, 4, 5, 2, 6, 10, 8, 7, 9 with the patient, listening for signs of laryngeal c. 3, 5, 1, 4, 2, 6, 10, 8, 7, 9 swelling d. 4, 1, 3, 5, 2, 6, 8, 9, 10, 7 c. Tell the patient a funny story as a means of allevi- 85. Venipuncture: ating anxiety about the procedure a. May be performed by a radiographer where d. Alert a radiologist allowed by state law 79. At the first indication of a contrast agent reaction, the b. May be performed by a nurse only radiographer should: c. Must be performed by a radiology supervisor a. Immediately shout for help d. May be performed by a radiographer under any b. Stop the examination and obtain help so as not to circumstances alarm the patient 86. A contrast medium overdose: c. Continue with the examination because most a. Cannot occur because a contrast medium is not a drug reactions turn out to be minor b. May occur in infants d. Call a respiratory or cardiac arrest code c. May occur if contrast material was injected during 80. Hypodermic needles are described by their gauge, the week before the examination which is a: d. May occur in infants or adults who have renal, car- a. List of the uses of the needle diac, or hepatic failure b. Measure of the length of the needle 87. If medication needs to be ordered for a patient in the c. Measure of the diameter of the needle radiology department, a physician always: d. Measure of the diameter of the needle opening— 1. Chooses the drug and the dosage the larger the gauge, the smaller the diameter 2. Selects the route of administration 81. Air must not be injected when performing venipunc- 3. Administers the drug ture because: a. 1 and 2 only a. An air embolus would form and may become fatal b. 1 and 3 only to the patient c. 2 and 3 only b. Most examinations requiring injection are not air d. 1, 2, and 3 contrast studies 88. A patient who has sustained a head injury in a motor c. It would interfere with the iodine vehicle accident arrived in the radiology department d. It would prevent visualization of the iodine alert and well oriented. While radiographing the 82. A smaller, easier-to-handle injection set that includes patient, the radiographer observed that the patient plastic projections on both sides of the needle and was becoming drowsy, irritable, and less coherent. may be used for venipuncture is called a: Which of the following would be the correct action a. Venous catheter for the radiographer to take? b. Butterfly a. Continue the radiographic examination c. Hypodermic needle b. Ignore the changes in the patient’s condition, and d. Single-injection needle place the patient back on the stretcher after com- 83. A venous catheter: pleting the examination a. Is less flexible and more difficult to use than a -nee c. Notify the department supervisor or the attending dle or butterfly physician of the change in the patient’s condition b. Is a combination unit with a needle inside a flex- d. Sound an emergency code alert ible plastic catheter; both the needle and the cath- 89. A reaction that causes the patient’s skin to turn cya- eter are inserted into the vein, after which the notic means: needle is withdrawn a. The skin is turning yellow c. Is only used for chemotherapy b. The skin is turning white 84. Place the following steps for performing venipuncture c. The skin is turning blue in the proper order. d. The skin is turning red 38 PART 1 Review and Study Guide

90. What degree of reaction is vomiting? 96. The formal term for “no code” is a(n): a. Mild to moderate reaction to contrast agent a. Advance directive b. Severe reaction to contrast agent b. Right to die c. Not considered a reaction to contrast agent c. Do not resuscitate (DNR) order 91. In patient care, the radiographer must be constantly d. Euthanasia aware of the myriad of variations among people of all 97. Which of the following contains points that are backgrounds and experiences. This involves the study enforceable? and understanding of: a. ARRT Mission Statement a. Nonverbal communication b. ARRT Code of Ethics b. Diversity c. ARRT Examination Content Specifications c. Verbal communication only d. ARRT Rules of Ethics d. Patient preferences 98. Which of the following serves as a guide to profes- 92. What degree of reaction is dyspnea? sional conduct? a. Mild to moderate reaction to contrast agent a. ARRT Mission Statement b. Severe reaction to contrast agent b. ARRT Code of Ethics c. Not considered a reaction to contrast agent c. ARRT Examination Content Specifications 93. Which of the following is always a part of the radiog- d. ARRT Rules of Ethics rapher’s scope of practice? 99. The patient may be left alone following injection of a a. Patient education contrast agent: b. Administration of medications a. Never c. Serve as a resource person for referring physicians b. After several minutes have passed and there is no d. Serving on the hospital’s radiation safety committee sign of a reaction 94. What degree of reaction is cardiac arrest? c. Immediately since contrast agent reactions are rare a. Mild to moderate reaction to contrast agent d. If they are of legal age b. Severe reaction to contrast agent 100. The study of contrast agents, their administration, c. Not considered a reaction to contrast agent and possible reactions fall under the category of: 95. A document that provides instructions regarding a. Nursing medical care that a patient may prepare before inca- b. Pharmacology pacitation is called a(n): c. Emergency care a. Preplanning order d. Respiratory care b. Advance directive c. Physician notice d. Informed consent 3 Safety

BASIC RADIATION PROTECTION TERMINOLOGY Ionizing radiation radiation that possesses the ability to NCRP Report #102 makes recommendations on equipment remove electrons from atoms by a process called ionization design and protection regarding lead shielding and fluoro- Somatic effects effects of radiation on the body being irradiated scopic and mobile exposure rates Genetic effects effects of radiation on the genetic code of a NCRP Report #116 defines annual exposure limits; makes cell; affects the next generation recommendations pertaining to risk–benefit analysis of Natural background radiation radiation contained in the radiation exposure; states that somatic and genetic effects unpolluted environment should be kept to a minimum when radiation is used for Artificially produced radiation also called man-made radiation diagnostic imaging (e.g., medical x-rays) Effective dose limit upper boundary dose that can be Primary radiation radiation exiting the x-ray tube absorbed, either in a single exposure or annually, with Exit radiation (remnant radiation; image-producing radia- a negligible risk of somatic or genetic damage to the tion) x-rays that emerge from the patient and strike the individual; effective dose implies whole-body radiation image receptor exposure Attenuation absorption and scatter (loss of intensity) of the Cumulative effective dose lifetime occupational exposure must x-ray beam as it passes through the patient not exceed the radiographer’s age multiplied by 10 mSv Heterogeneous beam x-ray beam that contains photons of Equivalent dose equal to the effective dose multiplied by the many different energies radiation weighting factor Photoelectric effect absorption of x-ray photons in the atoms As low as reasonably achievable (ALARA) concept of radio- of the body logic practice that encourages radiation users to adopt Compton effect scatter of x-ray photons from the atoms of the measures that keep the dose to the patient and themselves body at minimal levels Air kerma unit of exposure Dose-response curves graphs that illustrate the relationship Gray unit of absorbed dose, measured in joules per kilogram between radiation dose and the response of the organism to (J/kg); 1 Gy = 1 J/kg exposure; may be linear or nonlinear, threshold or non- Graya unit of radiation absorbed in air threshold Grayt unit of radiation absorbed in tissue Probabilistic (stochastic) effects randomly occurring effects Sievert unit of effective dose of radiation; the probability of such effects is proportional to Sievert unit of equivalent dose the dose (increased dose equals increased probability, not Becquerel unit of activity severity, of effects) National Academy of Sciences/National Research Council Deterministic effects effects of radiation that become more Committee on the Biological Effects of Ionizing Radiation severe at high levels of radiation exposure and do not occur (NAS/NRC-BEIR) organization that studies biological effects below a certain threshold dose of ionizing radiation and publishes resulting data Genetically significant dose (GSD) average annual gonadal International Commission on Radiologic Protection (ICRP) dose of radiation to individuals of childbearing age; organization that publishes international radiation protec- addresses the relationship of gonadal doses to individuals tion guidelines versus an entire population and the overall effects National Council on Radiation Protection and Measurements Linear energy transfer (LET) amount of energy deposited by (NCRP) organization that publishes radiation protection radiation per unit length of tissue guidelines for the United States Relative biological effectiveness (RBE) ability to produce Nuclear Regulatory Commission (NRC) organization that biological damage; varies with the LET enforces radiation protection standards at the federal level Direct effect effect that occurs when radiation directly strikes related to use of radioactive material DNA in the cellular nucleus

39 40 PART 1 Review and Study Guide

Indirect effect effect that occurs when radiation strikes the Late somatic effects of radiation carcinogenesis; cataracto- water molecules in the cytoplasm of the cell genesis; embryologic effects; thyroid dysfunction; life span Radiolysis of water effect that occurs as radiation energy is shortening deposited in the water of the cell; the result of radiolysis is Cardinal principles of radiation protection distance, time, an ion pair in the cell: a positively charged water molecule shielding (HOH+) and a free electron Distance best protection against radiation exposure Mutation erroneous information passed to subsequent genera- Personnel monitoring devices optically stimulated lumines- tions via cell division cence (OSL) badge, film badge, thermoluminescent dosim- Law of Bergonié and Tribondeau cells are most sensitive to eter (TLD) radiation when they are immature, undifferentiated, and Mean marrow dose average dose of radiation to the bone rapidly dividing marrow Early somatic effects of radiation hematopoietic syndrome; gastrointestinal (GI) syndrome; central nervous system syndrome

Units of Radiation Measurement D. Unit of effective dose 1. Estimates the risk present when various tissues are A. Unit of exposure irradiated 1. Air kerma 2. Uses a tissue weighting factor (WT); takes into a. Used to define radiation exposure or radiation account the relative radiosensitivity of the irradiated delivered to a specific point organ or body part b. Unit of measurement is gray (Gy)—normally 3. Unit of measurement tissue is sievert (Sv) expressed as Gya (a indicates air) 4. Effective dose is the product of absorbed dose times c. 1 Gy = 1 joule/kilogram (J/kg)—described as the radiation weighting factor times the tissue weight- energy absorption per kilogram of tissue irradiated ing factor (WT) d. Kerma is an acronym for kinetic energy released in 5. Calculated as Sv = Gy × WR × WT matter, kinetic energy released in material, kinetic E. Unit of radioactivity energy released per unit mass 1. Used to measure the quantity of radioactive mate- 2. Coulombs/kilogram rial (is not used to measure the radiation emitted but a. Sometimes used to measure exposure, though pre- rather the number of atoms decaying per second) ferred unit is air kerma 2. SI unit is the Becquerel (Bq) B. Unit of absorbed dose 3. Used primarily in nuclear medicine 1. Amount of energy absorbed per unit mass of tissue 2. Unit of measurement of tissue is gray (Gy); normally KEY REVIEW POINTS expressed as Gyt (t indicates tissue) C. Unit of equivalent dose (dose equivalent) Units of Radiation Measurement 1. The product of absorbed dose (Gy) times the radiation weighting factor (WR) • Gray—absorbed dose • Gray (Gy )—air kerma a. WR takes into account the biological impact of the a type and energy of the radiation being used • Gray (Gyt)—absorbed dose in tissue • Sievert (Sv)—unit of effective and equivalent dose b. WR takes into account linear energy transfer (LET), • Becquerel (Bq)—unit of radioactivity which is the amount of energy transferred by ionizing radiation per unit length of tissue traveled c. High-ionization radiations such as alpha particles and neutrons have high LET (cause more biological damage) Basic Principles of Radiation Protection d. Lower ionization radiations such as x-rays and Responsibility for Radiation Protection gamma rays have lower LET (cause less biological damage) A. Radiographer is primarily responsible for protecting the 2. Unit of measurement tissue is sievert (Sv) patient from unnecessary exposure 3. Calculated as: Sv = Gy × WR 1. Best accomplished by avoiding repeat exposures 4. Since the WR for x-rays and gamma rays is 1, 1 Sv = 1 Gy 2. Should use smallest amount of radiation that pro- when using those two forms of radiation duces a diagnostic radiographic image Chapter 3 Safety 41

B. Radiologist and referring physician assume shared KEY REVIEW POINTS responsibility for radiation safety of the patient 1. Best accomplished by consultation Ionizing Radiation 2. Should not order unnecessary exams C. Safe use of radiation in diagnostic imaging to determine • Ionizing radiation is able to remove electrons from atoms; the process is called ionization the extent of disease or injury should outweigh the risk • Ionization may cause unstable atoms, free electrons, or involved from the exposure formation of new molecules harmful to the cell • Two types of cell damage may occur: somatic (damage to the cell itself) or genetic (damage to the cell’s genetic Ionizing Radiation code) • Natural background radiation is present in the A. X-radiation exposure involves a transfer of energy environment through photon–tissue interactions • The greatest source of natural background exposure to 1. Possesses the ability to remove electrons from atoms humans is radon by a process called ionization • Human-produced radiation is created by human 2. Results of ionization in human cells activities (e.g., medical imaging) or inventions • CT accounts for the largest increase in total dose and a. Unstable atoms medical dose to the population b. Free electrons • Total radiation dose to the U.S. population has doubled c. Production of low-energy x-rays since the 1980s d. Formation of new molecules harmful to the cell e. Cell damage may be exhibited as abnormal function or loss of function Photon–Tissue Interactions B. General types of radiation damage 1. Somatic: Damage to the exposed individual A. Primary radiation: Radiation exiting the x-ray tube 2. Genetic: Damage to the genetic code of the germ cell B. Exit radiation (image-producing radiation): X-rays that contained in the DNA; may be passed to the next emerge from the patient and strike the image receptor; generation composed of primary and scattered photons C. Sources of ionizing radiation (though not tested on C. Attenuation: Absorption and scatter (loss of intensity) of the ARRT exam, this is presented here to provide the x-ray beam as it passes through the patient a comparison between natural and medical back- D. Heterogeneous beam: X-ray beam that contains photons ground sources of exposure as part of a course study of many different energies guide) E. Most common photon–tissue interactions in diagnostic 1. Total annual background radiation dose is 6.25 radiography are photoelectric and Compton interactions mSv annually (double compared with early 1. Photoelectric interaction (Figure 3-1) 1980s) a. Photon absorption interaction 2. Natural background radiation b. Incoming x-ray photon strikes a K-shell electron a. Contributes 3.0 mSv annually c. Energy of x-ray photon is transferred to electron b. Approximately 48% of total radiation dose d. Electron is ejected from the K-shell and is now c. Largest source of natural background radiation is called a photoelectron radon e. X-ray photon has deposited all of its energy and d. Other sources of natural background radiation are ceases to exist terrestrial, internal, and space (cosmic) f. Photon has been completely absorbed 3. Medical background radiation g. Photoelectron may ionize or excite other atoms a. Contributes 3.2 mSv (these data assume that med- until it has deposited all of its energy ical doses would be spread equally across the entire h. Hole in K-shell is filled by electrons from outer population) shells, releasing energy that creates low-energy b. Approximately 50% of total radiation dose characteristic photons that are locally absorbed c. Increase in total exposure is primarily attrib- i. Photoelectric interaction results in increased dose uted to increased use of computed tomography to the patient (CT) j. Photoelectric interaction produces contrast in the d. CT accounts for 24% of total radiation radiograph because of the differential absorption exposure of the incoming x-ray photons in the tissues 4. Other human-made background radiation 2. Compton interaction (Figure 3-2) a. Remaining 2% of effective dose a. Also called Compton scattering or modified scattering b. Sources—occupational exposure, various con- b. Incoming x-ray photon strikes a loosely bound, sumer products, and other sources outer-shell electron 42 PART 1 Review and Study Guide

Photoelectric effect f. Photon scatters in another direction with less energy Incident photon interacts than before because of its encounter with the electron with an inner orbital, K or g. Scattered photon may interact with other electrons, L, electron, giving all of its energy to the electron, causing more ionization, additional scattering events, ejecting it from orbit. The or photoelectric absorption; or it may exit the patient photon is “absorbed.” h. Scattered photons emerging from the patient travel in divergent paths in random directions i. Scattered photons may also be present in the room and expose the radiographer or radiologist 3. Coherent scatter (also known as classical scatter) The ejected electron (photoelectron) imparts the atom with a. Produced by low-energy x-ray photons an energy equal to the excess b. Atomic electrons are not removed but vibrate imparted by the photon. because of the deposition of energy from the photon c. As the electrons vibrate, they emit energy equal to that of the original photon d. This energy travels in a path slightly different from Photoelectric effect the path of the original photon There is a vacancy in the e. Ionization has not occurred, although the photon inner orbital, K or L, which has scattered must be filled. f. Does not affect image less than 70 kVp

One of the electrons from g. May have negligible effect on fog greater than 70 kVp outer orbital, usually the 4. Pair production next orbit out, drops to the void. a. Does not occur in radiography b. Produced at photon energies greater than 1.02 million electron volts As the electron drops to the void, it may shed its c. Involves an interaction between the incoming excess energy as a photon and the atomic nucleus secondary photon. 5. Photodisintegration—does not occur in diagnostic radiography

• Figure 3-1 The photoelectric effect is responsible for total absorp- KEY REVIEW POINTS tion of the incoming x-ray photon. Photon–Tissue Interactions Compton effect Photon interacts with outer • Attenuation describes changes in the intensity of the orbital electron, imparting some x-ray beam as it traverses the patient of its energy to the electron, • Two primary photon–tissue interactions are significant ejecting it from orbit. in diagnostic x-ray procedures—photoelectric and The ejected electron Compton (Compton electron) leaves • Photoelectric interaction results in complete absorption the atom with an energy of an incoming x-ray photon; this interaction produces equal to the excess contrast in the radiographic image imparted by the photon. • Compton interaction results in scattering of the incoming x-ray photon; scatter produced by this interaction must be removed from the beam before it The photon continues on an strikes the image receptor altered path, scattered, with • Compton scatter is the source of exposure to the less energy (longer wavelength) than before the collision. radiographer or radiologist during fluoroscopy

• Figure 3-2 During the Compton effect, the incoming photon loses energy and changes its direction. Annual Dose Limits

c. Photon transfers part of its energy to the A. Agencies involved in dose-response evaluations electron 1. International Commission on Radiological Protec- d. Electron is removed from orbit as a scattered elec- tion (ICRP) tron, referred to as a recoil electron a. Conducts research and provides recommendations e. Ejected electrons may ionize other atoms or on radiation protection to the worldwide commu- recombine with an ion needing an electron nity based on fundamental scientific principles Chapter 3 Safety 43 Response Response

Dose Dose • Figure 3-3 Linear-nonthreshold relationship. • Figure 3-4 Linear-threshold relationship.

b. Has no legal power c. Most countries base radiation protection legislation on ICRP recommendations 2. National Council on Radiation Protection and Mea- surements (NCRP)

a. Formulates and publishes scientifically researched Response recommendations on radiation protection and measurements in the United States 3. Nuclear Regulatory Commission (NRC) Dose a. Enforces radiation protection standards relating to • Figure 3-5 Nonlinear-threshold relationship. radioactive material at the federal level B. Effective dose limit 1. Upper boundary dose that can be absorbed, either in a single exposure or annually, with a negligible risk of somatic or genetic damage to the individual 2. As low as reasonably achievable (ALARA) a. Concept of radiologic practice that encourages Response radiation users to adopt measures that keep the dose to the patient and themselves at minimal levels C. Dose-response relationships Dose 1. Linear-nonthreshold relationship (Figure 3-3) • Figure 3-6 Nonlinear-nonthreshold relationship. a. Indicates that no level of radiation can be considered completely safe c. The degree of the response is not directly propor- b. A response occurs at every dose tional to the dose received c. The degree of response to exposure is directly pro- d. The effect is large even with a small increase in dose portional to the amount of radiation received 5. Stochastic effects: Randomly occurring effects of radia- 2. Linear-threshold relationship (Figure 3-4) tion; the probability of such effects is proportional to a. Indicates that at lower doses of radiation exposure the dose (increased dose equals increased probability, (to the left of the line intersecting the x-axis), no not severity, of effects) response is expected 6. Deterministic effects: Effects that become more severe b. When the threshold dose is exceeded, the response at high levels of radiation exposure and do not occur is directly proportional to the dose received below a certain threshold dose c. As an example, cataractogenesis does not occur at D. NCRP Report #116 low levels of radiation exposure; there is a threshold 1. Recommends balance between the risk and benefit dose below which cataractogenesis does not occur of using radiation for diagnostic imaging 3. Nonlinear-threshold relationship (Figure 3-5) 2. Recommends that somatic and genetic effects be a. Indicates that at lower doses of radiation exposure kept to a minimum when using radiation for diag- (to the left of the curve intersecting the x-axis), no nostic imaging response is expected 3. Takes into account all human organs that may be b. When the threshold dose is exceeded, the response vulnerable to radiation damage is not directly proportional to the dose received 4. Occupational exposure—annual effective dose limit and is increasingly effective per unit dose is 50 mSv 4. Nonlinear-nonthreshold relationship (Figure 3-6) 5. Occupational exposure—annual equivalent dose a. Indicates that no level of radiation can be consid- limits for deterministic effects ered completely safe a. Lens of the eye—150 mSv b. A response occurs at every dose b. Localized areas of skin, hands, feet—500 mSv 44 PART 1 Review and Study Guide

6. Cumulative effective dose limit = Age (in years) × C. Cytoplasm 10 mSv 1. Composed primarily of water 7. Students (older than age 18)—annual effective dose 2. Conducts all cellular metabolism limit is 50 mSv 3. Contains organelles 8. General public—annual effective dose limit for fre- a. Centrosomes: Participate in cell division quent exposure is 1 mSv b. Ribosomes: Synthesize protein 9. General public—annual effective dose limit for c. Lysosomes: Contain enzymes for intracellular diges- infrequent exposure is 5 mSv tive processes 10. Embryo-fetus—total equivalent dose for gestation d. Mitochondria: Produce energy is 5 mSv e. Golgi apparatus: Combines proteins with carbohy- 11. Embryo-fetus—equivalent dose limit per month is drates 0.5 mSv f. Endoplasmic reticulum: Acts as a transportation 12. Level of negligible risk is 0.01 mSv system to move food and molecules within the cell D. Nucleus 1. Contains deoxyribonucleic acid (DNA—the master KEY REVIEW POINTS molecule) and the nucleolus (with ribonucleic acid [RNA]) Annual Dose Limits 2. DNA controls cell division 3. DNA controls all cellular functions • Annual dose limits are published by the NCRP • Effective dose limit is the upper boundary dose that can E. Other cell components be absorbed, either in a single exposure or annually, 1. Proteins—15% of cell with a negligible risk of somatic or genetic damage to 2. Carbohydrates—1% of cell the individual 3. Lipids—2% of cell • The ALARA (as low as reasonably achievable) principle 4. Nucleic acids—1% of cell means that radiographers do what is possible to keep doses to patients and themselves at minimal levels 5. Water—80% of cell • Linear-nonthreshold relationship states that no level 6. Acids, bases, salts (electrolytes)—1% of cell of radiation can be considered completely safe, and the degree of response is directly proportional to the amount of radiation received Capitalize Division- Sv • Stochastic effects are randomly occurring effects of Mitosis: radiation; the probability of such effects is proportional A. Somatic cells to the dose (not related to the severity of effects) 1. Interphase • Deterministic effects become more severe at high levels a. Cell growth before mitosis of radiation exposure but do not occur below a certain b. Consists of three phases: G1, S, G2 threshold dose c. G1—pre-DNA synthesis • NCRP Report #116 contains recommendations for annual dose limits d. S—DNA synthesis • Annual effective dose limit for occupational exposure is e. G2—post-DNA synthesis, preparation for mitosis 50 mSv 2. Four subphases • Cumulative effective dose limit = age (in years) × 10 mSv a. Prophase—nucleus enlarges • Annual effective dose limit for the general public is 1 b. Metaphase—nucleus elongates mSv for frequent exposure and 5 mSv for infrequent exposure c. Anaphase—two complete sets of chromosomes • Effective dose limit for the embryo or fetus for all of d. Telophase—separates the two sets of genetic mate- gestation is 5.0 mSv rial; division complete; 46 chromosomes in each new somatic cell B. Meiosis: Cell division of sperm or ovum (germ cells) that halves the number of chromosomes in each cell Review of the Cell 1. Replication division Cell a. G1 b. S A. Contains three main parts c. G2 1. Cell membrane d. M 2. Cytoplasm 2. Reduction division 3. Nucleus a. G1 B. Cell membrane b. No S phase 1. Protects cell c. G2 2. Holds in water and nucleus d. M 3. Allows water, nutrients, and waste products to pass 3. Note: Sperm and ovum unite to return the number of into and out of the cell (it is semipermeable) chromosomes in each cell of the new individual to 46 Chapter 3 Safety 45

Biological Effects of Ionizing Radiation F. Positive and negative water molecules may be formed and then break into smaller molecules such as free radicals A. As LET of radiation increases, so does biological damage G. Free radicals: Highly reactive ions that have an unpaired B. Relative biologic effectiveness (RBE): Ability to produce electron in the outer shell biological damage; varies with LET H. Free radicals may cause biological damage by transfer- C. The R W used to calculate sievert is a measure of the RBE ring their excess energy to surrounding molecules or dis- of the radiation being used rupting chemical reactions D. Ionizing radiation may change the molecular structure I. Some free radicals may chemically combine to form of a cell, affecting its ability to function properly hydrogen peroxide (H2O2) E. Somatic cell exposure may result in a disruption in the J. Hydrogen peroxide is a poison that causes further dam- ability of the organism to function age to the cell F. Reproductive (germ) cell exposure may result in changes, K. The DNA in the cell may be affected by the free radicals called mutations, being passed on to the next generation or H2O2 G. Basically, radiation striking a cell deposits energy in L. Such action is called indirect because the DNA itself is either the DNA (a direct effect) or water in the cyto- not struck by the radiation plasm (an indirect effect) if an interaction occurs M. Indirect effect results from ionization or excitation of H. Most radiation passes through the body without inter- water molecules acting because atoms are composed mainly of empty N. Results of indirect effect space 1. No effect—most common response 2. Formation of free radicals Direct Effect 3. Formation of H2O2 O. Most damage to the body occurs as a result of the indi- A. Occurs when radiation transfers its energy directly to the rect effect because most of the body is water, and free DNA (the master molecule) or RNA radicals are readily mobile in water B. As these macromolecules are ionized, cell processes may be disrupted Target Theory C. Some of this damage may be repaired D. If the DNA structure incurs sufficient damage, particu- A. Each cell has a master molecule (DNA) that directs cell larly to its nitrogenous bases, a mutation may result activities E. Mutation: Erroneous information passed to subsequent B. If the DNA is the target of radiation damage and is inac- generations via cell division tivated, the cell dies F. Results of the direct effect C. DNA may be inactivated by either direct or indirect 1. No effect—most common result effects 2. Disruption of chemical bonds, causing alteration of D. All photon–cell interactions occur by chance cell structure and function E. Whether a given cell death was the result of direct or 3. Cell death indirect effects cannot be determined 4. Cell line death: Death of the tissues or organs that would have been produced from continued cell divi- Radiosensitivity of Cells sion had a cell survived; particularly significant if it results in the failure of a major organ or system to A. Law of Bergonié and Tribondeau: Cells are most sensitive develop to radiation when they are immature, undifferentiated, 5. Faulty information passed on in the next cell division; and rapidly dividing possible results include mutations, cancer, and abnor- B. If cells are more oxygenated, they are more susceptible mal formations to radiation damage (known as the oxygen enhancement ratio [OER]) Indirect Effect C. As cells mature and become specialized, they are less sensitive to radiation A. Because water is the largest constituent of the cell, the D. Blood cells: Whole-body dose of 25 rads depresses blood probability that it will be struck by radiation is greater count B. Radiolysis of water: Occurs as radiation energy is depos- 1. Caused by irradiation of bone marrow ited in the water of the cell 2. Lymphocytes are the most radiosensitive blood cells C. The result of radiolysis is an ion pair in the cell: a in the body positively charged water molecule (HOH+) and a free 3. Stem cells in bone marrow are especially radiosensitive electron E. Epithelial tissue: Highly radiosensitive, divides rapidly, D. Several possibilities exist for chemical reactions at this lines body tissue point; most reactions create further instability in the cell F. Muscle: Relatively insensitive because of high specializa- E. If the two ions recombine, no damage occurs tion and lack of cell division 46 PART 1 Review and Study Guide

G. Adult nerve tissue: Requires very high doses (beyond KEY REVIEW POINTS medical levels) to cause damage, is very specialized, has no cell division, is relatively insensitive to Cell radiation H. Reproductive cells • Main parts of the cell are the cell membrane, cytoplasm, and nucleus 1. Immature sperm cells: Very radiosensitive, divide rap- • Nucleus contains DNA idly, unspecialized, require 10 rads or more (which • Cytoplasm contains the organelles and water is beyond most commonly used diagnostic levels) to • Interphase: Portion of the cellular life cycle that occurs increase chances of mutation before mitosis 2. Ova in female fetus and child are very radiosensitive • Mitosis: Somatic cell division; comprises four phases: prophase, metaphase, anaphase, and telophase 3. Ovarian radiosensitivity decreases until near middle • When mitosis is complete, each new cell contains 46 age, then increases again chromosomes • Meiosis: Germ (sperm or ovum) cell division; halves the number of chromosomes in each cell so that the Somatic Effects of Radiation union of two germ cells produces a new cell with 46 chromosomes A. Somatic effects are evident in the organism being • LET: Amount of energy deposited per unit length of exposed travel of radiation passing through matter B. Doses causing these effects are much higher than the lev- • An increase in LET results in an increase in the potential els of radiation used in diagnostic radiography for biological damage C. Caused when a large dose of radiation is received by a • RBE: Ability of radiation to produce biological damage; it varies with LET large area of the body (can also be caused by local areas • Direct effect: Occurs when radiation transfers its of the body receiving high doses of radiation during energy directly to the DNA (the master molecule) or radiation therapy) RNA D. Examples of early somatic effects of radiation (acute • Mutation: Erroneous information passed to subsequent radiation syndrome) generations via cell division • Indirect effect: Occurs when radiation transfers its 1. Hematopoietic syndrome: Decreases total number of energy to the water in the cytoplasm; may cause all blood cells; can result in death radiolysis and produce free radicals or H2O2 2. GI syndrome: Causes total disruption of GI tract • Law of Bergonié and Tribondeau: Cells are most structure and function and can result in death sensitive to radiation when they are immature, 3. Central nervous system syndrome: Causes complete fail- undifferentiated, and rapidly dividing • OER: If cells are more oxygenated, they are more ure of nervous system and results in death susceptible to radiation damage E. Examples of late somatic effects • As cells mature and become specialized, they are less 1. Carcinogenesis: Causes cancer sensitive to radiation 2. Cataractogenesis: Causes cataracts to form; follows a • Lymphocytes are the most radiosensitive blood cells in nonlinear-threshold dose-response curve the body • Stem cells in bone marrow are especially radiosensitive 3. Embryologic effects: Most sensitive during the first • Epithelial tissue: Highly radiosensitive trimester of gestation • Muscle: Relatively insensitive to radiation 4. Thyroid: Very radiosensitive organ; late somatic effect • Adult nerve tissue: Requires very high doses of may be cancer or cessation of function radiation (beyond medical levels) to cause damage; 5. Shortening of life span: Does not occur in modern is relatively insensitive to radiation • Immature sperm cells: Very radiosensitive radiation workers • Ova in female fetus and child: Very radiosensitive • Ova radiosensitivity decreases until near middle age, then increases again Genetic Effects of Radiation • Somatic effects manifest in the individual being A. Caused by damage to DNA molecule, which is passed to exposed • Early somatic effects: Hematopoietic syndrome, GI the next generation syndrome, central nervous system syndrome B. Follows a linear-nonthreshold dose-response curve; no • Late somatic effects: Carcinogenesis, cataractogenesis, such thing as a safe gonadal dose; any exposure can rep- embryologic effects, life span shortening resent a genetic threat • Genetic effects: Manifest in the next generation C. Usually causes recessive mutations, so generally not because of damage to the DNA; follow a linear- nonthreshold curve manifested in the population • Doubling dose: Amount of radiation that causes the D. Doubling dose: Amount of radiation that causes the num- number of mutations in a population to double; estimated ber of mutations in a population to double (is approxi- to be 1.56 Sv for humans mately 1.56 Sv for humans) E. Genetic mutations do not cause defects that are not already present in humans from other causes; that is, no defects are unique to radiation exposure Chapter 3 Safety 47

Patient Exposure and Protection Filtration The heart of radiation protection for the patient lies in the con- A filter is placed in the x-ray beam to remove long-wave- cept of ALARA. It is primarily the radiographer’s responsibility length (low-energy) x-rays. Low-energy x-rays contrib- to see that ALARA is in practice so that patients are properly ute nothing to the diagnostic image but increase patient protected. Taking adequate histories, communicating clearly, dose through the photoelectric effect. As low-energy rays using proper immobilization, and conducting radiographic and are removed, the beam becomes “harder” (predominantly fluoroscopic exams calmly and professionally add to the level of short-wavelength, high-energy). This process of removing safety your patients will encounter while under your care. This low-energy rays results in a lower patient dose. section reviews the many technical aspects of the radiographer’s A. Two types of filtration: inherent and added practice that contribute to ALARA for the patient. B. Inherent filtration 1. Glass envelope of the x-ray tube Beam Limitation 2. Insulating oil around the tube 3. Diagonal mirror used for positioning light Beam limitation protects the patient by limiting the area of C. Added filtration the body and the volume of tissue being irradiated 1. Aluminum sheets placed in the path of the beam near A. Collimator the x-ray tube window 1. Variable aperture device 2. Mirror placed in the collimator head 2. Contains two sets of lead shutters placed at right D. Total filtration angles to each other 1. Equals inherent plus added filtration 3. Higher set of lead shutters is placed near the x-ray 2. Must equal at least 2.5-mm aluminum equivalent for tube window to absorb off-stem (off-focus) radiation x-ray tubes operating at greater than 70 kVp 4. Lower set of lead shutters is placed near the bottom of E. Half-value layer: Amount of filtration that reduces the collimator box to restrict the beam further as it exits the intensity of the x-ray beam to half of its original 5. Accuracy of the collimator is subject to strict quality value—measured at least annually by a qualified radia- control standards (see Chapter 4) tion physicist 6. Collimation should be no larger than the size of the F. The radiographer never adjusts added tube filtration; if image receptor being used it is suspected that the filtration has been altered, the 7. Collimators that automatically restrict the beam to x-ray tube must not be used until checked by a radiation the size of the image receptor have a feature called physicist positive beam limitation (PBL), also called automatic collimation Gonadal Shields 8. PBL responds when an image receptor is placed in the tray containing sensors that measure its size Gonadal shields are used to protect gonads from unneces- B. Cylinder cones sary radiation exposure. They should be used whenever they 1. Metal cylinders that attach to the bottom of the col- do not obstruct the area of clinical interest. limator A. Gonadal shielding may reduce female gonad dose by up 2. Used to restrict the beam tightly to a small circle to 50% 3. Diameter of the far end of the cone determines field B. Gonadal shielding may reduce male gonad dose by up to size 95% 4. Cones may be extended an additional 10 to 12 inches C. Proper collimation may also greatly reduce gonadal dose by a telescoping action for even tighter restriction of and should be used in conjunction with gonadal shields the beam D. Most commonly used gonadal shields 5. Cones may be used for exam of the os calcis, various 1. Flat contact shield: Flat piece of lead or a lead apron skull projections, and cone-down views of vertebral placed over the gonads bodies 2. Shadow shield: Suspended from the x-ray tube hous- 6. Use of cones results in a restriction of the x-ray beam ing and placed in the x-ray beam light field; requires by cutting out a major portion of the beam no contact with the patient; especially useful during 7. When cones are used, mAs must always be increased procedures requiring sterile technique to make up for the rays attenuated by the cone 8. Cylinder cones do not work by focusing the x-ray Exposure Factors beam down the cone; x-rays cannot be focused C. Aperture diaphragm Exposure technique determines the quantity and quality of 1. Flat piece of lead with a circle or square opening in x-rays striking the patient the middle A. Use optimal kVp for the part being radiographed 2. Placed as close to the x-ray tube window as possible B. Use the lowest possible mAs to reduce the amount of 3. Has no moving parts radiation striking the patient 48 PART 1 Review and Study Guide

C. The part being imaged should be measured with calipers 15. Personnel during fluoroscopy should stand on the D. A reliable technique chart should be consulted to deter- image intensifier side of the C-arm during lateral or mine the proper exposure factors to use oblique projections E. Use of automatic exposure controls (AEC) reduces the 16. When possible, use the C-arm with the x-ray tube number of repeat exposures below the patient for anteroposterior and posteroanterior projections Grids 17. During fluoroscopy, the radiographer should always wear the radiation dosimeter outside of the lead A. Result in an increase in patient dose because increased apron at the level of the collar mAs are required 18. Avoid use of electronic magnification modes on B. Use appropriate type and ratio of grid for part being the image intensifier when possible because this imaged and exam being performed increases the dose to the patient and other persons in the room Repeat Exposures 19. Air kerma a. Provides an approximate skin dose where the A. Always result in an increase in radiation dose to the x-ray beam is entering the patient patient . b Is displayed during a fluoroscopic procedure B. Must be kept to a minimum c. Monitoring air kerma is a way to keep dose to C. Should be tracked via a departmental repeat exposure the patient lower, especially during prolonged analysis fluoroscopic procedures D. Reasons for repeat exposures should be documented d. Expressed as Gya (a indicates energy deposited in E. In-service education for areas of frequent repeat expo- a mass of air) sures should be conducted by qualified radiographers or 20. Dose area product (DAP)—the total of air kerma radiologists striking the surface of the patient a. May be read on the DAP meter on the fluoro- Technical Standards for Patient Protection scopic monitor . b Expressed as mGy-cm2 A. Minimum source-to-skin distance for portable radiogra- 21. Last image hold (LIH) phy: at least 12 inches . a Provides for keeping the most recently acquired flu- B. Fluoroscopy oroscopic image displayed on the monitor without 1. Use of intermittent fluoroscopy (as opposed to a continued radiation exposure to the patient constant beam-on condition) . b Using last image hold reduces patient exposure 2. Tight collimation of the beam by allowing the fluoroscopist to evaluate an 3. High kVp image without continuing to expose the patient 4. Source-to-tabletop distance for fixed fluoroscopes: 22. Automatic brightness control (ABC) or automatic not less than 15 inches exposure rate control (AERC) 5. Source-to-tabletop distance for portable fluoro- a. kVp and mA are automatically adjusted during scopes: not less than 12 inches fluoroscopy, which keeps image brightness level 6. Proper filtration of the beam . b The ABC or AERC delivers to the image receptor 7. Fluoroscopy timer that sounds alarm after 5 min- only the exposure that is required to maintain utes (300 seconds) of beam-on time the necessary image quality 8. Fluoroscopy timer should not be reset before alarm goes off; fluoroscopist must be made aware of time Other Factors Relating to Patient Dose that the patient and other persons in the room were exposed A. Measuring patient dose 9. Exposure switch must be dead-man type 1. Skin entrance dose 10. Limit dose at the tabletop to no more than 100 mGya 2. Mean marrow dose (MMD): Average dose to active per minute bone marrow 11. Limit use of high-level-control fluoroscopy (HLCF) B. Genetically significant dose (GSD): Radiation dose that, if during interventional procedures to no more than received by the entire population, would cause the same 200 mGya per minute genetic injury as the total of doses received by the per- 12. Long exposure times (>30 minutes) can lead to skin sons actually being exposed; the average gonadal dose to effects; the patient should be informed of the pos- the childbearing-age population sibility of skin injury (e.g., erythema, epilation) C. Pediatrics: Children need to be carefully protected 13. Fluoroscopy times should be recorded from unnecessary exposure; high-speed image receptors 14. Pulsed fluoroscopy or low-dose modes should be should be used along with adequate immobilization used when possible to achieve ALARA objectives D. Pregnant patients Chapter 3 Safety 49

1. It is the responsibility of the referring physician to Cardinal Principles of Radiation Protection determine whether a diagnostic exam involving x-rays is necessary; the benefit should outweigh the A. Time: Amount of exposure is directly proportional to risk; if the abdomen or pelvis is involved, the radiolo- duration of exposure gist should communicate the risk of the exam to the B. Distance: Most effective protection from ionizing radiation referring physician and the patient 1. Dose is governed by the inverse square law 2. Most diagnostic x-ray exams have equivalent doses of 2. The greater the distance from the radiation, the lower less than 0.01 mSv the dose 3. Radiation doses of less than 0.01 mSv to the embryo 3. Dose varies inversely according to the square of the or fetus are considered lower risk distance; for example, if the exposure is 5 mGya at a distance of 3 feet, stepping back to a distance of 6 feet causes the exposure to decrease to 1.25 mGya KEY REVIEW POINTS 4. The inverse square law should always be used during fluoroscopy in which close contact with the patient Patient Exposure and Protection is not required and during mobile radiography and • Always observe the ALARA principle fluoroscopy • Beam limiters: Collimator, cylinder cones, aperture C. Shielding: Lead-equivalent shielding absorbs most of the diaphragms energy of the scatter radiation • PBL: Positive beam limitation, or automatic collimation 1. A lead apron of at least 0.25-mm lead equivalent must • Beam filtration: Removes long-wavelength rays; total be worn (0.5-mm lead equivalent should be worn) filtration must be at least 2.5-mm aluminum equivalent • Gonadal shielding: May reduce female gonad dose by during exposure to scatter radiation; a thyroid shield up to 50%; may reduce male gonad dose by up to 95% of at least 0.5-mm lead equivalent should be worn for • Exposure factors: Use optimum kVp for the part; use fluoroscopy lowest practical mAs 2. The radiographer should never be exposed to the pri- • Grids remove scatter radiation from exit beam; increase mary beam total dose to the patient because of the increased mAs needed 3. If exposure of the radiographer to the primary beam • Maintain a minimum of 12 inches source-to-skin is unavoidable, the exam should not be performed distance for portable radiography 4. Family members of the patient, nonradiology employ- • Use intermittent fluoroscopy ees, or radiology personnel not routinely exposed • Maintain a minimum of 15 inches source-to-tabletop should be the first choices to assist with immobiliza- distance for fixed fluoroscopes • Maintain a minimum of 12 inches source-to-tabletop tion of the patient for an exam when all other types distance for portable fluoroscopes (15 inches preferred) of immobilization have proved inadequate • Monitor fluoroscopy timer that must sound alarm after 5 5. The radiographer should be the last person chosen to minutes (300 seconds) of beam-on time assist with immobilization during an exposure • Fluoroscopy foot switch must be dead-man type 6. Radiographers and student radiographers should not • Fluoroscopy dose at the tabletop is limited to no more be viewed as quick and easy-to-use immobilization than 100 mGya per minute • MMD: Average dose to active bone marrow devices • GSD: Radiation dose that, if received by the entire 7. Thickness recommendations for lead devices have population, would cause the same genetic injury as been determined by NCRP Report #102 the total of doses received by the persons actually being exposed; the average gonadal dose to the childbearing-age population Source of Radiation Exposure to Radiographer A. Source of radiation exposure to the radiographer is scatter radiation produced by Compton interactions in the patient Radiation Worker Exposure and Protection B. Greatest exposure to the radiographer occurs during fluoroscopy, portable radiography, and surgical radiog- The ALARA concept applies to radiographers as well as raphy to patients. Many of the steps taken to reduce the dose to C. It is vital that lead aprons be worn when fluoroscopy and the patient also reduce the dose to the radiographer. How- mobile radiography or fluoroscopy is performed ever, additional steps may be taken to protect the radiation D. Photons lose considerable energy after scattering 1 worker further. Agency standards also apply to the equip- E. Scattered beam intensity is about ⁄1000 the intensity of ment used by radiographers. This section reviews practices the primary beam at a 90-degree angle at a distance of 1 and standards used to protect occupationally exposed indi- m from the patient viduals. As you study the factors involved in protecting the F. Beam collimation helps reduce the incidence of Comp- radiation worker, reexamine the annual effective dose limits ton interactions, resulting in decreased scatter from the covered previously. patient 50 PART 1 Review and Study Guide

G. The use of high-speed image receptors may further C. Bucky slot shield: Minimum 0.25-mm lead equivalent reduce the amount of scatter produced because of D. 5-minute timer with audible alarm decreased quantity of radiation needed for exposure Portable Radiographic Equipment and Structural Protective Barriers Procedure A. Primary protective barriers A. Exposure switch must be on a cord at least 6 feet long 1 1. Consist of ⁄16-inch lead equivalent B. Lead aprons must be worn if mobile barriers are unavail- 2. Located where primary beam may strike the wall or able floor C. Least scatter is at a 90-degree angle from patient 3. If in the wall, extend from the floor to a height of 7 D. Apply the inverse square law to reduce dose by using feet exposure cord at full length B. Secondary protective barriers E. Radiographer should never hold the image receptor in 1 1. Consist of ⁄32-inch lead equivalent place for a portable exam because of possible exposure to 2. Extend from where primary protective barrier ends to the primary beam the ceiling, with ½-inch overlap F. Commercial image receptor holders, pillows, and 3. Located wherever leakage or scatter radiation may sponges should be used to hold the image receptor in strike place 4. X-ray control booth is also a secondary protective barrier KEY REVIEW POINTS a. Exposure switch must have a cord short enough that the radiographer has to be behind the second- Radiation Worker Exposure and Protection ary protective barrier to operate the switch b. Lead window by control booth is usually 1.5-mm • Cardinal principles of radiation protection: Time, lead equivalent distance, shielding; distance is the best protection • Dose is governed by the inverse square law C. Determinants of barrier thickness • Lead apron: Must be at least 0.25-mm lead equivalent; 1. Distance: Between the source of radiation and the should be at least 0.5-mm lead equivalent barrier • The radiographer must never be exposed to the primary 2. Occupancy: Who occupies a given area beam a. Uncontrolled area: Areas where personnel are not • Source of radiation exposure to radiographer is scatter radiation produced by Compton interactions in the provided radiation exposure monitors (dosimeters) patient during fluoroscopy, portable radiography, and or radiation safety training should be shielded to surgical radiography 1 ensure an effective dose limit to the general public • Scattered beam intensity is about ⁄1000 the intensity of of 20 μSv per week the primary beam at a 90-degree angle at a distance of b. Controlled area: Occupied by persons trained in 1 m from the patient • Beam collimation helps reduce the incidence of radiation safety and wearing personnel monitoring Compton interactions, resulting in decreased scatter devices; shielded to keep exposure under 1 mSv from the patient 1 per week • Primary protective barriers: Must be at least ⁄16-inch 3. Workload: Measured in mA minutes per week (mA lead equivalent and extend from the floor to a height of min/wk); takes into account the volume and types of 7 feet • Secondary protective barriers: Must be at least exams performed in the room 1 ⁄32-inch lead equivalent and extend from the primary 4. Use factor: Amount of time the beam is on and protective barrier to the ceiling with a ½-inch overlap directed at a particular barrier • Determinants of barrier thickness: Distance, occupancy, workload, use • Uncontrolled area: General public areas such as waiting X-ray Tube Housing rooms and stairways • Controlled area: Occupied by persons trained in A. X-rays may leak through the housing during an radiation safety and wearing personnel monitoring exposure devices B. Patient and all others present in the room must be pro- • X-ray tube leakage: May not exceed 1 mGya per hour at tected from excess leakage radiation a distance of 1 m from the housing • Fluoroscopic protective curtain: Minimum 0.25-mm C. Leakage radiation may not exceed 1 mGya per hour at a lead equivalent distance of 1 m from the housing • Bucky slot shield: Minimum 0.25-mm lead equivalent • Portable x-ray machine exposure switch must be on a Fluoroscopic Equipment cord at least 6 feet long A. Exposure switch: Must be dead-man type B. Protective curtain: Minimum 0.25-mm lead equivalent Chapter 3 Safety 51

7. Filters made of aluminum and copper measure inten- Monitoring Radiation Exposure sity and type of radiation striking the film badge Monitoring Personnel Exposure 8. Film badges are usually changed monthly A. Optically stimulated luminescence (OSL) dosimeters Monitoring Area Exposure 1. Use aluminum oxide to record dose 2. Radiation absorbed causes electrons to be trapped A. Handheld ionization chamber 3. Aluminum oxide layer is stimulated by a laser beam 1. Used to measure radiation in an area (e.g., a fluoro- after wear period scopic room), storage areas for radioisotopes, doses 4. Electrons release energy as visible light traveling through barriers, and patients who have 5. Light is in direct proportion to the amount of radia- radioactive sources within them tion received 2. Not used to monitor short exposure times 6. Measures exposures as low as 10 μGya 3. Measures exposure rates as low as 10 μGya per hour 7. Relatively unaffected by temperature and humidity 4. Operates on a principle similar to the pocket ioniza- 8. Can be worn 3 months at a time tion chamber, with internal gas being ionized when 9. Can be reanalyzed multiple times, if necessary struck by radiation 10. Exposures below 10 μGya are reported as minimal B. Geiger-Mueller detector B. Thermoluminescent dosimeters (TLDs) 1. Used to detect radioactive particles in nuclear medi- 1. Use lithium fluoride crystals instead of film to cine facilities record dose 2. Sounds audible alarm when struck by radiation, with 2. Electrons of crystals are excited by radiation expo- sound increasing as radiation becomes more intense sure and release this energy on heating 3. Meter reads in counts per minute 3. Energy released is visible light, which is measured by a photomultiplier tube 4. Light is in direct proportion to the amount of radia- KEY REVIEW POINTS tion received Monitoring Radiation Exposure 5. TLDs are used mainly in ring badges worn by nuclear medicine technologists • OSL dosimeters: Aluminum oxide layer stores energy 6. Measure exposures as low as 50 μGya that is released when exposed to a laser; correlate to 7. Relatively unaffected by temperature and humidity dose; provide readings as low as 10 μGya; insensitive to 8. Can be worn for longer periods than film badges environmental factors • TLDs: Store energy in lithium fluoride crystals 9. TLDs and equipment used to read them are expensive that is released when heated; correlate to dose; 10. Exposures below 50 μGya are reported as minimal provide readings as low as 50 μGya; insensitive to C. Film badges—available but not often used today environmental factors 1. Consist of plastic case, film, and filters • Film badges: Use small piece of x-ray film; provide 2. Plastic case holds film and filters and provides a clip readings as low as 100 μGya; sensitive to extremes in temperature and humidity for attaching to clothing • Handheld ionization chamber: Used to measure 3. Film used is similar to dental x-ray film radiation in an area; measures doses of 10 μGya per 4. Measure doses as low as 100 μGya μ hour • Geiger -Mueller detector: Used to detect radioactive 5. Doses below 100 μGya μ are reported as minimal 6. Film is sensitive to extremes in temperature and particles; meter reads in counts per minute humidity

Review Questions 1. Natural background radiation represents what per- 3. Cosmic radiation: centage of humans’ radiation exposure? a. Is present only in space a. 21% b. Is a source of exposure only to persons who lie in b. 50% the sun c. 82% c. Is of concern only to space travelers d. 5% d. Is a part of natural background exposure 2. The greatest source of natural background radiation 4. Radon gas: exposure is: a. Presents a danger when undetected a. Cosmic rays b. Is present in doses proportional to other sources b. Radioactive materials c. Is entirely human-made c. The body itself d. Is the source of 100% of annual background d. Radon gas dose 52 PART 1 Review and Study Guide

5. X-rays and gamma rays used in diagnostic imaging are: b. Compton interaction a. Not of concern because the beam is filtered c. Coherent scatter b. Part of the natural background dose d. Pair production c. Part of an artificial background radiation dose 15. Which of the following results in total absorption of d. An insignificant dose to the general population an incident x-ray photon? because they are used safely a. Photoelectric interaction 6. A feature of fluoroscopic x-ray machines that auto- b. Compton interaction matically adjusts kVp and mA so as to maintain c. Classic scatter image brightness for necessary image quality is called: d. Pair production a. Automatic imaging 16. Which of the following is the only photon–tissue b. Automatic brightness control (ABC) interaction that does not result in ionization? c. Automatic image processing a. Photoelectric interaction d. Constant exposure output b. Compton interaction 7. What term best describes the approximate skin dose c. Coherent scatter where the x-ray beam is entering the patient? d. Pair production a. Effective dose 17. Which of the following involves interaction between b. Nonoccupational dose an incident photon and an atomic nucleus? c. In-air exposure a. Photoelectric interaction d. Air kerma b. Compton interaction 8. Sievert is calculated by multiplying gray by c. Coherent scatter a. WR d. Pair production b. Wa 18. Which of the following photon–tissue interactions c. Wt primarily involves K-shell electrons? d. mAs a. Photoelectric interaction 9. The total of air kerma over the exposed area of the b. Compton interaction patient is called: c. Coherent scatter a. Dose area product d. Pair production b. Mean marrow dose 19. Which of the following primarily involves loosely c. Genetically significant dose bound outer-shell electrons? d. Total patient dose a. Photoelectric interaction 10. Which of the following is also known as coherent scat- b. Compton interaction tering? c. Coherent scatter a. Photoelectric interaction d. Pair production b. Compton interaction 20. Which of the following results in the production of a c. Classical scatter photoelectron that is ejected from the atom? d. Pair production a. Photoelectric interaction 11. Which of the following photon–tissue interactions b. Compton interaction does not occur in diagnostic radiography? c. Coherent scatter a. Photoelectric interaction d. Pair production b. Compton interaction 21. Which of the following photon–tissue interactions c. Coherent scatter necessitates the use of a grid? d. Pair production a. Photoelectric interaction 12. Which of the following is responsible for creating the b. Compton interaction conditions for contrast on the image? c. Coherent scatter a. Photoelectric interaction d. Pair production b. Compton interaction 22. Which of the following may result in occupational c. Coherent scatter exposure for a radiographer? d. Pair production a. Photoelectric interaction 13. Which of the following produces scatter radiation b. Compton interaction that exits the patient and may fog the image? c. Coherent scatter a. Photoelectric interaction d. Pair production b. Compton interaction 23. What unit of measurement is used for absorbed dose c. Coherent scatter in tissue? d. Pair production a. Gy a 14. Which of the following produces scatter as a result of b. Gy s vibration of orbital electrons? c. Gy b a. Photoelectric interaction d. Gy t Chapter 3 Safety 53

24. What unit of measurement is used for effective dose 31. What are graphs called that show the relationship limits? between dose of radiation received and incidence of a. Becquerel effects? b. Gy t a. Nonlinear-nonthreshold effect c. Sievert b. Linear-nonthreshold effect d. Gy a c. Radiation-effect curves 25. Which of the following units would be used to d. Dose-response curves describe the radiation present in a fluoroscopic room? 32. Which of the following is the basis for all radiation a. Bq protection standards? b. Sv a. Nonlinear-nonthreshold effect c. Gy a b. Linear-nonthreshold effect d. Gy t c. Linear-threshold effect 26. The amount of energy deposited by radiation per unit d. Nonlinear-threshold effect length of tissue being traversed is: 33. Which of the following means there is no safe a. LET, which determines the use of a WR when the level of radiation and the response to the radia- equivalent dose is being calculated tion is not directly proportional to the dose b. Linear energy transfer received? c. Higher for wave radiations than for particulate a. Nonlinear-nonthreshold effect radiations b. Linear-nonthreshold effect d. LET, which is expressed as a WR when absorbed c. Linear-threshold effect dose is being calculated d. Nonlinear-threshold effect 27. What agency publishes radiation protection standards 34. Which of the following means there is no safe level of based on scientific research? radiation and the response to the radiation is directly a. Nuclear Regulatory Commission (NRC) proportional to the dose received? b. American Society of Radiologic Technologists a. Nonlinear-nonthreshold effect (ASRT) b. Linear-nonthreshold effect c. National Council on Radiation Protection and c. Linear-threshold effect Measurements (NCRP) d. Nonlinear-threshold effect d. Bureau of Radiological Health (BRH) 35. Which of the following means there is a safe level 28. The agency that enforces radiation protection stan- of radiation for certain effects and those effects are dards relating to radioactive material at the federal directly proportional to the dose received when the level is the: safe level is exceeded? a. Nuclear Regulatory Commission (NRC) a. Nonlinear-nonthreshold effect b. International Commission on Radiation Protec- b. Linear-nonthreshold effect tion (ICRP) c. Linear-threshold effect c. National Council on Radiation Protection and d. Nonlinear-threshold effect Measurements (NCRP) 36. Which of the following means there is a safe level of d. Bureau of Radiological Health (BRH) radiation for certain effects and those effects are not 29. Effective dose limit is defined as the upper boundary directly proportional to the dose received when the dose that: safe level is exceeded? a. Can be absorbed annually with a negligible risk of a. Nonlinear-nonthreshold effect somatic or genetic damage to the individual b. Linear-nonthreshold effect b. Can be absorbed, either in a single exposure or c. Linear-threshold effect annually, with no risk of damage to the individual d. Nonlinear-threshold effect c. Can be absorbed, either in a single exposure or 37. Effects of radiation where the probability of occur- annually, with no risk of somatic or genetic dam- rence, not severity of occurrence, is proportional to age to the individual the dose are called: d. Can be absorbed, either in a single exposure a. Stochastic effects or annually, with a negligible risk of somatic or b. Deterministic effects genetic damage to the individual c. Genetic effects 30. ALARA is an acronym for: d. Somatic effects a. As long as reasonably achievable 38. Effects of radiation that become more severe as dose b. As little as reasonably achievable increases are called: c. As long as radiologist allows a. Dose-response curves d. A radiation protection concept that encourages b. Deterministic effects radiation users to keep the dose to the patient as c. Genetic effects low as reasonably achievable d. Somatic effects 54 PART 1 Review and Study Guide

39. According to NCRP Report #116, what is the embryo c. LET or fetus equivalent dose limit per month? d. Pregnancy a. 0.5 mSv 48. LET and biological damage are: b. 0.1 mSv a. Directly proportional c. 5 mSv b. Indirectly proportional d. 0.05 mSv c. Inversely proportional 40. According to NCRP Report #116, the occupational d. Unrelated cumulative effective dose limit = age in years × what dose? 49. The ability of different types of radiation to pro- a. 5 mSv duce the same biological response in an organism b. 0.1 mSv is called: c. 0.5 mSv a. LET d. 10 mSv b. WR 41. According to NCRP Report #116, the annual occu- c. RBE pational effective dose limit is: d. Doubling dose a. 50 mSv 50. The phases of the cellular life cycle, in order, are: b. 10 mSv a. Prophase, metaphase, anaphase, telophase c. 0.50 mSv b. Interphase, prophase, metaphase, anaphase, telophase d. 0.05 mSv c. G1, S, G2, telophase 42. According to NCRP Report #116, what is the annual d. Interphase (G1, S, G2), prophase, metaphase, ana- effective dose limit for radiography students older phase, telophase than age 18? 51. The process of cell division for germ cells is called: a. 50 mSv a. Mitosis b. 10 mSv b. Spermatogenesis c. 0.50 mSv c. Organogenesis d. 0.05 mSv d. Meiosis 43. According to NCRP Report #116, what is the annual 52. Which of the following occurs when radiation trans- effective dose limit for the general public, assuming fers its energy to DNA? infrequent exposure? a. Indirect effect a. 5 mSv b. Target theory b. 0.1 mSv c. Direct effect c. 10 mSv d. Mutations d. 0.05 mSv 53. Which of the following states that each cell has a mas- 44. According to NCRP Report #116, what is the embryo ter molecule that directs all cellular activities and that, or fetus equivalent dose limit for gestation? if inactivated, results in cellular death? a. 5 mSv a. Indirect effect b. 10 mSv b. Target theory c. 0.5 mSv c. Direct effect d. 0.05 mSv d. Mutations 45. According to NCRP Report #116, what is the annual 54. Which of the following describes the amount of radi- effective dose limit for the general public, assuming ation required to increase the number of mutations in frequent exposure? a population by a factor of 2? a. 5 mSv a. Indirect effect b. 1.0 mSv b. Target theory c. 0.5 mSv c. Doubling dose d. 0.05 mSv d. Mutations 46. According to NCRP Report #116, what is the annual 55. What occurs when radiation transfers its energy to effective occupational dose limit for the lens of the the cellular cytoplasm? eye? a. Indirect effect a. 1.5 mSv b. Target theory b. 1.0 mSv c. Direct effect c. 100 mSv d. Doubling dose d. 150 mSv 56. Which of the following induces radiolysis? 47. The WR used in calculating sievert takes into account a. Indirect effect which of the following? b. Target theory a. Meiosis c. Direct effect b. Age d. Doubling dose Chapter 3 Safety 55

57. What is the name for changes in genetic code passed 67. Cells that are least sensitive to radiation exposure include: on to the next generation? a. Ova and sperm a. Indirect effect b. Epithelial cells b. Target theory c. Nerve and muscle cells c. Direct effect d. Blood cells d. Mutations 68. Compared with ova in younger and older women, ova 58. Which of the following is responsible for producing in women of reproductive age are: free radicals? a. More radiosensitive a. Indirect effect b. Less radiosensitive b. Target theory c. About the same c. Direct effect 69. Most somatic effects occur: d. Doubling dose a. At doses delivered during diagnostic radiography 59. What occurs when the master molecule is struck by b. At doses beyond doses used during diagnostic radiation? radiography a. Indirect effect c. In middle age b. Target theory d. In old age because of an increase in medical care c. Direct effect 70. Somatic effects manifest in: d. Doubling dose a. The person who has been irradiated 60. Which of the following poisons the cell with H2O2? b. The next generation a. Indirect effect c. Newborns b. Target theory d. Imaging technologists c. Direct effect 71. Which of the following is considered a late somatic d. Doubling dose effect? 61. Most of the damage to a cell occurs as a result of: a. Carcinogenesis a. Direct effect b. Genetic effect b. Mutations c. Alzheimer disease c. Law of Bergonié and Tribondeau d. Parkinson disease d. Indirect effect 72. Which of the following is used to limit the area of the 62. Cell radiosensitivity is described by the: patient being irradiated? a. Inverse square law a. Grid b. Law of Bergonié and Tribondeau b. Lead mask c. Reciprocity law c. Collimator d. Ohm’s law d. Compensating filter 63. The law that states that cells are most sensitive to 73. Gonadal shields may reduce exposure to female radiation when they are nonspecialized and rapidly gonads by up to: dividing is the: a. 50% a. Inverse square law b. 95% b. Law of Bergonié and Tribondeau c. 10% c. Reciprocity law d. 75% d. Ohm’s law 74. Which of the following sets of exposure factors would 64. Cells are more radiosensitive when: result in the lowest dose to the patient? a. Fully oxygenated a. High mAs, low kVp b. Deoxygenated b. Low mAs, high kVp c. Slowly dividing c. Low mAs, high kVp, small focal spot d. Near the skin d. Low mAs, high kVp, large focal spot 65. Blood count can be depressed with a whole-body 75. Which of the following is used as part of an effort to dose of: practice the ALARA concept? a. 0.25 Sv a. Grids b. 25 Sv b. Increased mAs c. 1 Sv c. Collimation d. 10 Sv d. Thinner filtration 66. The most radiosensitive cells in the body are: 76. The cardinal rules of radiation protection include: a. Lymphocytes a. Collimation, gonadal shielding, no repeats b. Epithelial cells b. Collimation, short exposure time, no repeats c. Nerve cells c. Shielding, distance, time d. Muscle cells d. Time, distance, collimation 56 PART 1 Review and Study Guide

77. Which of the following is used to survey an area for c. MMD radiation detection and measurement? d. DMM a. TLD 87. The radiation dose that would cause the same b. Film badge genetic injury to the population as the sum of doses c. Handheld ionization chamber received by individuals actually being exposed is d. Geiger-Mueller detector called: 78. Which of the following is accurate as low as 100 a. GSD μGya? b. ALARA a. TLD c. MMD b. Film badge d. MPD c. OSL 88. The timer used in fluoroscopy: d. Handheld ionization chamber a. Must be 3 minutes 79. Which of the following includes filters for measure- b. Should always be reset before the alarm sounds so ment of radiation energy? that it does not annoy the radiologist a. TLD c. Sounds an alarm after 3 minutes b. Film badge d. Is used to alert the fluoroscopist after 5 minutes of c. OSL fluoroscopy scanning have elapsed d. Handheld ionization chamber 89. The most effective protection against radiation expo- 80. Which of the following may be used to measure in-air sure for the radiographer is: exposures in a fluoroscopic room? a. Lead apron a. TLD b. Lead gloves b. Film badge c. Lead glasses c. Handheld ionization chamber d. Distance d. Geiger-Mueller detector 90. If the dose of scatter radiation in fluoroscopy to the 81. What detection device sounds an alarm to indicate radiographer is 10 mGya at a distance of 2 feet from the presence of radioactivity? the table, where should the radiographer stand to a. TLD reduce the dose to 2.5 mGya? b. Film badge a. 8 feet from the table c. Pocket ionization chamber b. 4 feet from the table d. Geiger-Mueller detector c. At the foot of the table 82. Which of the following is accurate as low as 50 μGya? d. Directly behind the fluoroscopist a. TLD 91. Lead aprons used in fluoroscopy must be at least: b. Film badge a. 0.5-mm lead c. Pocket ionization chamber b. 0.25-mm lead d. Handheld ionization chamber c. 0.1-mm lead 83. Which of the following is a digital monitor that may d. 0.25-mm lead equivalent be used to measure dose in an area? 92. Which of the following is true concerning holding of a. TLD patients for radiographic exams? b. Film badge a. May be performed routinely to obtain a diagnostic c. Pocket ionization chamber exam d. Handheld ionization chamber b. Should be done only when absolutely necessary, 84. Which of the following may be used for 3 months at and then the holding should be done by a com- a time? petent radiographer so that a repeat will not be a. TLD needed b. Film badge c. Should be done only when absolutely necessary, c. Pocket ionization chamber and then the holding should be done by a non- d. Geiger-Mueller detector pregnant member of the patient’s family 85. Which of the following is sensitive to extremes in d. May be performed using a student radiographer to environment? hold because students are not exposed as often as a. TLD staff radiographers b. Film badge 93. The factors that must be considered in the design of c. Pocket ionization chamber structural shielding for a radiology room or depart- d. Handheld ionization chamber ment include: 86. Which of the following is used to represent the mean a. Use, occupancy, workload marrow dose? b. Time, distance, shielding a. GSD c. Occupational and nonoccupational exposure b. ALARA d. Number of employees and number of students Chapter 3 Safety 57

94. The lowest intensity of scatter radiation from the c. OSL dosimeter patient is located: d. Geiger-Mueller detector a. At the head of the table 98. Minimum source-to-skin distance for mobile radiog- b. At a 90-degree angle from the patient raphy must be: c. At a 180-degree angle from the patient a. 15 inches d. At the foot of the table b. 12 inches 95. Minimal (M) readings on dosimeter reports mean: c. 36 inches a. A dose below the sensitivity of the dosimeter has d. 55 inches been received 99. Positive beam limitation is also known as: b. A maximum dose has been received a. Use of collimators c. A mean (average) dose has been received b. Beam limitation used for all exams d. Much radiation has been received c. Use of beam restrictors 96. A readout on the fluoroscopic monitor that indicates d. Automatic collimation air kerma striking the surface of the patient is: 100. Added tube filtration should be adjusted by the a. mA meter radiographer: b. DAP meter a. To “harden” the x-ray beam c. ESD meter b. To remove the soft rays from the x-ray beam d. kVp meter c. To exercise radiation protection 97. Which of the following is the most sensitive person- d. Never nel monitoring device? a. TLD b. Film badge 4 Image Production

X-RAY EQUIPMENT OPERATION

Basic Physics Terminology determines the chemical element; all chemical elements are Matter has form or shape and occupies space represented in the periodic table of elements Mass amount of matter in an object; generally considered the Isotopes atoms with the same number of protons but with a same as weight different number of neutrons Energy ability to do work Electron-binding energy force that holds electrons in orbit Potential energy energy of position around the nucleus Kinetic energy energy of motion Octet rule outer shell of an atom may not contain more than Chemical energy energy resulting from a chemical reaction eight electrons Electrical energy energy resulting from movement of Particulate radiation alpha particles (helium nucleus—two electrons protons and two neutrons); beta particles (electronlike par- Thermal energy heat energy resulting from movement of ticles emitted from the nucleus of a radioactive atom) atoms or molecules Nuclear energy energy resulting from the nucleus of an atom Characteristics of Electromagnetic Radiation Electromagnetic energy energy that is emitted and transferred Photon smallest amount of any type of electromagnetic radia- through matter tion; also considered a bundle of energy called a quantum; Ionizing radiation electromagnetic radiation that is able to travels at the speed of light; travels in waves in a straight remove an electron from an atom path Ionization removal of an electron from an atom Sine waves waves of electromagnetic radiation; wave height is called amplitude; distance between the peaks of waves is Measurement Standards called wavelength; as photon wavelength decreases, photon Length meter energy increases Mass kilogram Frequency number of wavelengths passing a given point per Time second unit time; measured in hertz (Hz) SI system meter, kilogram, second Speed of travel electromagnetic radiation travels at the speed MKS system meter, kilogram, second of light (186,000 miles per second); travel at the speed of CGS system centimeter, gram, second light is constant, regardless of wavelength or frequency; British system foot, pound, second wavelength and frequency of electromagnetic radiation are Velocity (speed) how fast an object is moving inversely proportional Acceleration rate of change of speed per unit of time Gamma rays electromagnetic rays produced in the nucleus of Work force applied on an object over a distance radioactive atoms; x-rays and gamma rays differ only in their Power rate of doing work (measured in watts) origin Wave-particle duality concept that although x-ray photons exist as waves, they exhibit properties of particles Atomic Structure Attenuation partial absorption of the energy of an x-ray beam Atomic nucleus contains protons (positive charges) and neu- as it traverses an object trons (no charge); contains most of the mass of an atom Inverse square law law that governs the intensity of x-radia- Atomic mass number of protons plus number of neutrons; tion; states that the intensity of the x-ray beam is inversely represented by the letter A proportional to the square of the distance between the Electron shells contain orbital electrons (negative charges); source of the x-rays and the object represented by the letters K, L, M, N, O, P, and Q; in a stable Law of conservation of matter matter cannot be created or atom, the number of electrons and protons is equal destroyed, only changed in form Atomic number of an atom equals the number of protons in Law of conservation of energy energy cannot be created or the nucleus; represented by the letter Z; the atomic number destroyed, only changed in form

58 Chapter 4 Image Production 59

Principles of Electricity and Magnetism Self-induction opposing voltage created in a conductor by Electrostatics stationary electrical charges (static electricity) passing alternating current through it Electrification movement of electrons between objects Mutual induction inducing current flow in a secondary coil by Laws of electrostatics unlike charges attract, and like charges varying the current flow through a primary coil repel; electrostatic charges reside on the outer surface of Electrical generator device that converts mechanical energy a conductor and are concentrated at the area of greatest to electrical energy; usual output of an electrical generator is curvature; only negative charges move alternating current Methods of electrification friction, contact, and induction Single-phase, two-pulse alternating current simplest type of Conductor material that allows the free flow of electrons current; voltage (and accompanying current) flows as a sine Insulator object that prohibits the flow of electrons wave; voltage begins at zero, peaks at full value at the crest Electrical current movement of electrons along a conductor or of the wave, returns to zero, reverses, and again peaks on the pathway (electrical circuit); measured in amperes inverse portion of the cycle at the trough Electromotive force (EMF) measured in volts; the force with Three-phase alternating current special wiring patterns (“wye,” which electrons move in an electrical circuit “star,” “delta”) used to create voltage waveforms that are Electrodynamics electrical charges in motion placed 120 degrees out of phase with one another; these Semiconductor material that may act as an insulator or con- voltage waveforms are called three-phase; three-phase ductor under different conditions waveforms may have 6 pulses per cycle or 12 pulses per Electrical resistance measured in ohms cycle; three-phase, 6-pulse waveforms contain 360 pulses Ohm’s law voltage in the circuit is equal to the current × resis- per second; three-phase, 12-pulse waveforms contain 720 tance pulses per second; high-frequency generators produce high- Electrical circuits path along which electrons flow; may be frequency electricity (thousands of hertz) wired as series circuits or parallel circuits Electrical motor device that converts electrical energy to Alternating current (AC) electrical circuit in which the current mechanical energy of electrons oscillates back and forth Transformer changes electrical voltage and current into Direct current (DC) unidirectional flow of electrons in an elec- higher or lower values; the transformer operates on the trical conductor principle of mutual induction, so it requires alternating Sine wave representation of electron flow as alternating current current Step-up transformer transformer that increases voltage from Magnetic field energy field surrounding an electrical the primary to the secondary coil and decreases current in charge in motion; can magnetize a ferromagnetic the same proportion; a step-up transformer has more turns material, such as iron, if the material is placed in the in the secondary than in the primary coil; a step-up trans- magnetic field former is used in the x-ray circuit to increase voltage to the Magnetic poles every magnet has a north pole and a south kilovoltage level for x-ray production pole Step-down transformer transformer that decreases voltage Laws of magnetics like poles repel, and unlike poles attract; the from the primary to the secondary coil and increases current force of attraction between poles is governed by the inverse in the same proportion; a step-down transformer has more square law turns in the primary than in the secondary coil; a step-down Electromagnetism movement of electrons in a conductor transformer is used in the filament portion of the x-ray circuit produces a magnetic field around the conductor; a coiled to increase current flow to the cathode conductor (i.e., a wire), through which an electrical current is Autotransformer transformer that contains an iron core and flowing, has overlapping magnetic fields a single winding of wire; an autotransformer is used in the Solenoid stacks of wire coil through which electrical current x-ray circuit to provide a small increase in voltage before flows, creating overlapping force field lines; a magnetic field the step-up transformer; the kVp settings are made at the is concentrated through the center of the coil autotransformer Electromagnet solenoid with an iron core that concentrates Rectification process of changing alternating current to direct the magnetic field current Electromagnetic induction process of causing an electrical Line voltage compensation x-ray circuit depends on a constant current to flow in a conductor when it is placed within source of power; power coming into the radiology depart- the magnetic field of another conductor; two types of ment may vary; line voltage compensator keeps incoming electromagnetic induction are self-induction and mutual voltage adjusted to proper value; usually operates automati- induction cally but may be manually adjusted on older equipment 60 PART 1 Review and Study Guide

Conditions Necessary for the Production 3. Placed in the circuit between the autotransformer of X-Rays and the high-voltage transformer C. Timer A. Source of electrons 1. Used to regulate the duration of x-ray exposure B. Acceleration of electrons 2. Wired in the circuit between the autotransformer and C. Sudden stoppage of electrons against target material the high-voltage transformer 3. mAs timer a. Provides the safest tube current in the shortest Equipment Used in the Production of time possible X-Rays (Figure 4-1) b. Measures total tube current c. Located after the secondary coil of the high- A. Autotransformer voltage transformer 1. Also known as a variable transformer d. Used with falling load generators 2. Provides for the variation of voltage flowing in the 4. Electronic timer x-ray circuit and applied to the x-ray tube a. Microprocessor controlled 3. Single coil of wire with an iron core b. Contained in most radiographic equipment 4. Source for selecting kVp c. Allows exposure times of 1 ms (0.001 second) 5. Operates on the principle of self-induction 5. Automatic exposure control (AEC) a. Single winding of wire incorporates both the pri- a. Used to provide consistency of radiographic qual- mary and the secondary coils of the transformer ity 6. Primary turns are fed 220 V from the radiology b. Relies on excellent positioning skills and exten- department’s incoming line sive knowledge of surface and internal anatomy 7. Secondary turns (secondary taps) are selected by the because the part being imaged must be accurately radiographer using the kVp select control positioned over ionization sensors 8. Voltage is stepped up or stepped down by only a small c. Requires proper ionization chambers be selected amount and sent to the primary side of the high- for part being imaged voltage step-up transformer d. Consists of a flat ionization chamber that is located 9. The high-voltage step-up transformer boosts the volt- between the patient and the image receptor age to the kVp that was selected e. Uses fixed kVp while machine controls mAs B. Prereading voltmeter f. As radiation passes through the ionization cham- 1. The voltmeter in the x-ray circuit indicates the volt- ber, it ionizes the gas contained inside age that is selected g. When a predetermined level of ionization is 2. Called prereading because it indicates the kilovoltage reached (allowing time for a sufficient amount that will be flowing through the tube once the expo- of radiation to pass through to strike the image sure is made receptor), the electronics terminate the exposure

CONTROL CONSOLE HIGH-VOLTAGE SECTION X-RAY TUBE

Autotransformer

Timing circuit and Major selector kVp selector kVp mA meter meter

Line monitor Minor mA kVp selector selector Focal spot selector Line compensator switch and meter

• Figure 4-1 Simplified electrical circuit diagram for an x-ray machine. Chapter 4 Image Production 61

h. Backup timer must be set to terminate the expo- 5. The turns ratio may be 500 to 1000, depending on sure in the event of a malfunction the machine i. Backup timer protects the patient from overexpo- 6. Voltage is varied at the autotransformer and sent to sure and the x-ray tube from overheating the high-voltage transformer j. Minimum response time: Shortest time possi- 7. Turns ratio in the step-up transformer is not varied ble with an AEC because of the time it takes to E. Rectifier operate 1. X-ray tube requires direct current to operate properly k. Shortest time with an AEC is 1 ms (0.001 second) 2. Rectifier changes alternating current coming from l. Varying kVp when using AEC does not alter the step-up transformer to direct current receptor exposure, although contrast changes 3. Rectifiers are solid-state semiconductor diodes m. Varying kVp serves to alter penetrating ability of the a. Consist of silicon-based n-type and p-type semi- beam, resulting in faster or shorter exposure time conductors n. Changing ± controls on AEC allows exposure to 4. Located between the step-up transformer and the be increased or decreased; each step normally rep- x-ray tube resents a change of 25% in receptor exposure 5. Unit with four diodes provides full-wave rectification 6. Falling load generator for single-phase generator a. Modern generator that takes advantage of extre a. Full-wave rectification produces pulsating direct mely short time capabilities and tube heat-loading current potential b. Resultant waveform contains two pulses per cycle b. Radiographer sets mAs and kVp (120 pulses per second) c. Falling load generator calculates the most efficient c. Uses both portions of rectified alternating current method of obtaining the required mAs d. Results in 100% ripple, with voltage dropping to d. X-ray tube current starts at highest level possible zero 120 times per second for first portion of the exposure e. X-ray production ceases 120 times per second e. When the maximum heat load of the tube has been 6. Unit with 6 or 12 diodes provides full-wave rectifica- reached for that mA, the generator decreases the tion for three-phase equipment mA to the next lower level that the tube can handle a. Because three-phase current is used, voltage never f. The exposure continues at progressively lower lev- drops to zero during the exposure els of mA for the shortest times possible until the b. Voltage ripple for three-phase, 6-pulse is approxi- desired mAs is reached mately 13%; the voltage actually used is about g. Falling load generator always uses the shortest 87% of the kVp set times possible to obtain a given mAs c. Voltage ripple for three-phase, 12-pulse is approxi- h. Disadvantages: Exams in which long exposure mately 4%; the voltage actually used is about 96% times are used (e.g., breathing techniques for lat- of the kVp set eral thoracic spine); rapid-sequence exposures in d. Voltage ripple for high-frequency generators is which heat buildup in the tube may cause expo- approximately 1%; the voltage actually used is sure times to increase about 99% of the kVp set D. Step-up transformer (high-voltage transformer) e. High-frequency units result in lower patient dose 1. Consists of primary coils and secondary coils f. Three-phase, full-wave rectified waveforms pro- 2. Requires alternating current to operate duce higher average photon energy (35% higher 3. Primary coil receives voltage from the autotransformer for three-phase, 6-pulse; 41% higher for three- a. Operates on principle of mutual induction phase, 12-pulse) b. Magnetic field surrounding a wire with electricity g. Three-phase and high-frequency units produce flowing through it induces (causes) electricity to 12% to 16% more x-rays than single-phase units flow in a second wire placed within the force field h. kVp values used with single-phase equipment may 4. Voltage in the primary coil is boosted to the kilovolt- be decreased 12% to 16% when the same exam age level (thousands of volts) in the secondary coil is performed on three-phase or high-frequency a. Number of turns of the wire in the primary coil equipment compared with the number of turns of the wire in F. Milliammeter (mA meter) the secondary coil is called the turns ratio 1. Measures tube current in milliamperes b. Turns ratio determines how much the voltage is 2. Wired between the rectifier and x-ray tube stepped up G. mA control (filament circuit) c. The greater the turns ratio, the higher the resulting 1. Regulates the number of electrons available at the kilovoltage filament to produce x-rays d. Voltage is being induced in the secondary coil, 2. Voltage is provided by tapping windings of the auto- which has many more wire turns than the primary transformer and varying the voltage being sent to the coil step-down transformer 62 PART 1 Review and Study Guide

a. Step-down transformer reduces voltage and increa b. Must be able to tolerate extremely high levels of ses current in response to the use of variable resis- heat produced during x-ray production tors (rheostats) manipulated by the radiographer c. Anode rotates from 3300 to 10,000 rpm, depend- via the mA stations on the control panel ing on tube design b. Resultant high current is sent on to heat the filament d. Rotation is achieved by the use of an induction c. A filament ammeter may also be connected motor located outside the x-ray tube, which turns H. X-ray tube (Figure 4-2) a rotor located inside the x-ray tube; the target is 1. Cathode assembly: Negative electrode in the x-ray tube attached at the end of the rotor a. Contains two filaments—small and large e. Rotation of the target allows greater heat dissipation b. Filaments are made of tungsten (because of its f. Rotation of the target is stopped by a braking high melting point); a small amount of thorium is action provided by the induction motor added to reduce vaporization and prolong tube life g. X-ray machine should never be shut off imme- c. Filaments are heated slightly when the x-ray diately after an exposure; machine should not be machine is turned on; no electrons are ejected at shut off until the target has stopped rotating this low level of heating h. Without the braking action, the target may spin d. During x-ray exposure, one filament is heated to for 30 minutes, causing great strain on the bearings a level that causes electrons to be “boiled off” in i. Electrons strike the target on the focal track (some- preparation for x-ray production (which is known times called the focal spot) as thermionic emission) j. The focal track is beveled, producing the target angle e. Over time, filaments vaporize and coat the inner k. Target angle allows for a larger actual focal spot surface of the x-ray tube with tungsten, leading to (area bombarded by electrons), while producing a tube failure smaller effective focal spot (the area seen by the f. Cathode assembly also includes the focusing cup image receptor) g. The focusing cup surrounds the filaments on three l. The larger the actual focal spot, the greater the sides heat capacity; the smaller the effective focal spot, h. The focusing cup has a negative charge applied, the greater the radiographic image sharpness which tends to concentrate electrons boiling off m. This effect is called theline-focus principle the filaments into a narrower stream and repels n. Target angle may be 7 to 20 degrees, depending on them toward the anode tube design i. Electron concentration keeps the electrons aimed o. Exposure switch should be activated in one con- at a smaller area of the anode tinuous motion, activating the rotor and then the j. Some x-ray tubes use the focusing cup as an elec- exposure button tronic grid that can turn the tube current on and p. The equipment allows the rotor to come up to off rapidly, allowing very short and precise expo- speed before making the exposure sure times, such as times needed for rapid serial q. Radiographer does not control this by activat- exposures (referred to as a grid-controlled tube) ing the rotor and waiting to press the exposure 2. Anode: Positive electrode in the x-ray tube button a. Consists of a metal target made of a tungsten– r. Activating the rotor and allowing it to operate by rhenium alloy (because of its high melting point and itself results only in unnecessary heating of the high atomic number) embedded in a disk (or base) of filament and wear on the induction motor, short- molybdenum with a motor to rotate the target ening tube life 3. Glass envelope with window a. Cathode and target are inside the glass envelope; Stator Anode Tungsten/rhenium stem anode disk some models use a partial metal envelope b. Glass envelope also contains a vacuum so that electrons from the filament do not collide with atoms of gas Rotor c. Tube window: Thinner section of glass envelope (ϩ)(Ϫ) that allows x-rays to escape 4. Tube housing: Encases the x-ray tube a. Made of aluminum with lead lining Anode Cathode b. Supports and protects the tube, restricts leakage radiation during exposure, and provides electrical Filament Glass Port in envelope insulation focusing cup c. Also contains oil in which the x-ray tube is • Figure 4-2 Structure of a typical x-ray tube, including the major immersed to assist with cooling and additional operational parts. electrical insulation Chapter 4 Image Production 63

X-Ray Production high-voltage step-up transformer, where they are boosted to kilovoltage levels A. Making the exposure 10. After leaving the secondary coils of the step-up trans- 1. The x-ray machine is turned on, and a small amount former, the voltage and alternating current are sent of current is sent to the filament to warm it and ready through the rectifier, which changes the alternating it for much higher current current to pulsating direct current 2. Radiographer takes equipment through warm-up 11. The kilovoltage creates a high potential difference exposures to warm the filament further and warm the in the x-ray circuit, making the anode less nega- anode tive (relatively positive) and the cathode highly 3. Radiographer chooses exposure factors on control negative console for the exam to be performed with the assis- 12. This high potential difference causes the electrons tance of technique charts to move at very high speed (approximately half the a. Measurement speed of light) from the cathode to the anode 1. Part thickness should always be measured using 13. The collision of these projectile electrons with the calipers atoms of the target material causes a conversion of 2. Caliper measurement is used to consult the the kinetic energy of the electrons (100%) to heat technique chart (99.8%) and x-rays (0.2%) b. Types of technique charts 14. Heat is produced when the projectile electrons strike 1. Fixed kVp–variable mAs the outer shell electrons of the target material and a. Assumes optimal kVp for the part being place them in an excited state, which causes them to radiographed emit infrared radiation b. Except for exceptionally large patients, kVp 15. The production of x-rays comes from two interac- never changes for a given projection tions with the anode c. mAs is varied according to the part thickness B. Bremsstrahlung (brems) radiation (Figure 4-3) as measured with the calipers 1. A projectile electron misses outer shell electrons in d. Based on the assumption that thicker parts the target and moves in close to the nucleus absorb more rays and more rays must be 2. Because the nucleus is positive and the electron is placed in the primary beam negative, it is slowed or braked 2. Variable kVp–fixed mAs 3. The reduction in kinetic energy causes the electron to a. kVp is varied according to part thickness as slow and release energy as an x-ray photon measured with the calipers 4. The resultant x-rays are called bremsstrahlung (brak- b. Based on the assumption that thicker parts ing) x-rays because they are produced by the slowing require a beam with shorter wavelength rays (braking) of projectile electrons that are more penetrating 5. At diagnostic levels, most x-rays produced are from 3. Variable technique (vary both mAs and kVp) brems interaction a. Provides for alteration of routine techniques because of pathologic conditions, patient age, ability to cooperate, body mass index, Ϫ casts, or contrast media Incident Ϫ High-energy electron bremsstrahlung Ϫ Ϫ 4. Electricity coming into the radiology department is Ϫ Ϫ Ϫ Ϫ Ϫ x-ray photon adjusted by the line voltage compensator in the x-ray Ϫ ϪϪ Ϫ Ϫ Ϫ Ϫ Ϫ equipment to maintain it at a constant level Ϫ Ϫ Ϫ 5. When making the exposure, the radiographer presses Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ the rotor switch and exposure switch in one continu- Ϫ Ϫ Ϫ Ϫ Ϫ ous motion Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ 6. The induction motor begins spinning the anode; the Ϫ Ϫ Ϫ filament gets hotter Ϫ Ϫ 7. When the exposure switch is closed, the voltage Ϫ Ϫ Ϫ Ϫ Ϫ selected by the mA control flows from the autotrans- Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ former, through the variable resistors, and into the Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ step-down transformer in the filament circuit Ϫ Ϫ Ϫ 8. The filament heats considerably, boils off electrons Ϫ Ϫ (thermionic emission), and creates a space charge or Ϫ Incident Ϫ electron cloud around the filament electron Low-energy 9. At the same time, the alternating current and volt- bremsstrahlung age the radiographer selects by choosing taps off the x-ray photon autotransformer are sent to the primary coils of the • Figure 4-3 Bremsstrahlung interaction. 64 PART 1 Review and Study Guide

C. Characteristic radiation (Figure 4-4) 5. Travel in straight lines as waves 1. A projectile electron collides with an inner shell a. Wavelength of diagnostic x-rays: 0.1 to 0.5 ang- electron of a target atom stroms (Å) (1 Å × 10−10 m, which is one 10- 2. It removes the inner shell electron from orbit and billionth of a meter) ionizes the atom b. Wavelength is the distance from crest to crest or 3. A hole exists in the inner shell from the vacated elec- trough to trough, or the distance covered by one tron complete sine wave 4. An electron from an outer shell falls in to fill the c. Frequency: The number of waves passing a given hole point per unit time 5. As the electron falls in, energy is given off in the d. Wavelength and frequency are inversely propor- form of an x-ray photon tional to one another; as wavelength increases, 6. This creates a hole in its shell of origin, and an frequency decreases, and as wavelength decreases, electron from the next outer shell falls in to fill frequency increases this vacancy; this continues until the atom is stable e. Short-wavelength rays are more penetrating; again long-wavelength rays are less penetrating 7. Each time an electron falls in to fill a hole, an x-ray 6. Invisible to the human eye photon is given off 7. Have characteristics of waves and particles; travel in 8. Each x-ray photon has a specific energy, equal to the bundles or packets of energy called photons difference in the binding energies of the two shells 8. Exist in a wide range of wavelengths and energies involved 9. Can ionize matter and gases 9. Only x-rays produced at the K-shell are of sufficient 10. Cause fluorescence of phosphors energy to be used in diagnostic radiography 11. Unable to be focused by a lens 10. Because the x-rays possess energy characteristic of 12. Liberate a small amount of heat when passing the specific binding energies of the atom involved, through matter they are called characteristic x-rays 13. Electrically neutral 11. Characteristic x-rays are produced at kVp levels 14. Affect photographic film greater than 70 but only in small numbers 15. Cause biological and chemical changes through D. X-ray properties excitation and ionization 1. Part of the electromagnetic radiation spectrum 16. Scatter and produce secondary radiation 2. Highly penetrating E. X-ray beam characteristics 3. Invisible 1. Because x-rays are produced by brems and charac- 4. Travel at the speed of light (186,000 miles per teristic interactions at the anode, the resultant x-ray second) beam contains many different energies 2. An x-ray beam containing many different energies is

Ϫ called heterogeneous Ϫ 3. The collection of all different energies (wavelengths)

Ϫ Ϫ of x-rays is called the x-ray emission spectrum Ϫ Ϫ Ϫ Ϫ Ϫ 4. Discrete x-ray spectrum: Produced by characteristic Ϫ Ϫ ϪϪ Ϫ Ϫ Ϫ Ϫ x-rays because energies involved are specific to the Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ target atom and are predictable Ϫ Ϫ Ϫ Ϫ Ϫ 5. Continuous x-ray spectrum: Produced by brems radia- Incident Ϫ Ϫ electron Ϫ Ϫ tion because these energies all are different (from the Ϫ ϩ Ϫ Ϫ Ϫ 74 p Ϫ Ϫ Ϫ Ϫ peak electron energy down to zero energy) 110 n° Ϫ Ϫ 6. The maximum energy an x-ray photon can have cor- Ϫ Ϫ Ϫ responds to the kVp that was used Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ 7. Beam characteristics may be altered by using filtration Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ a. A filter is usually a sheet of aluminum placed in Ϫ Ϫ Ϫ Ϫ Ϫ Ϫ the primary beam just as it exits the x-ray tube and Ϫ Ϫ Ϫ Ϫ Ϫ before it reaches the collimator Ϫ b. The oil and glass envelope of the x-ray tube offer inherent filtration c. Total beam filtration equals inherent filtration K-shell O-shell plus added filtration M-shell L-shell N-shell d. Total filtration must be at least 2.5-mm aluminum Characteristic equivalent x-ray photons e. Filtration removes the low-energy (long-wave- • Figure 4-4 Characteristic interaction. length, “soft”) rays from the beam Chapter 4 Image Production 65

f. The result of removing soft rays from the beam is a • Step-down transformer: Operates on principle of lower patient skin dose mutual induction; steps down voltage, steps up g. Other types of filters that directly affect the radio- current graphic image may be used, known as compensat- • X-ray tube: Consists of two electrodes—cathode ing filters (e.g., wedge, boomerang) (negative) and anode (positive) • Cathode: Contains filaments, the source of electrons for h. Half-value layer: Amount of filtration that reduces exposure the beam intensity by half • Focusing cup: Attempts to narrow the stream of F. Heat units and their management electrons as it leaves the cathode filament 1. Heat units are a calculation of the total heat produced • Anode: Metal target where electron energy is converted during an x-ray exposure to x-ray energy and heat energy • Focal spot (focal track): Area on anode where electrons 2. Heat units are calculated using the following equa- strike, from where x-rays emanate tions: • Exposure switch: Consists of rotor (begins rotation a. Single-phase, full-wave rectified equipment: kVp of the anode and boiling electrons off of filament) × mAs and exposure button (closes circuit allowing flow of b. Three-phase, 6-pulse, full-wave rectified equip- electrons through the x-ray tube) • Leaded glass envelope: Encircles the anode and ment: kVp × mAs × 1.35 (Remember: This equip- cathode and provides a vacuum inside the x-ray ment produces x-ray photons with 35% higher tube average photon energy) • Tube housing: Encases the x-ray tube; aluminum lined c. Three-phase, 12-pulse, full-wave rectified equip- with lead ment: kVp × mAs × 1.41 (Remember: This equip- • X-ray production: Occurs when current inside the x-ray tube flows from the cathode and is suddenly stopped ment produces x-ray photons with 41% higher at the anode average photon energy) • More than 99% of electrons’ energy is converted to 3. X-ray tubes and tube housing are constructed to heat; less than 1% is converted to x-rays absorb certain levels of heat units • Brems: X-rays produced by slowing of incoming 4. Most modern x-ray equipment automatically pre- electrons by the target atoms; slowing releases energy in the form of x-rays vents the user from making an exposure capable of • Characteristic: X-rays produced when incoming producing too much heat in the tube; this is indi- electrons at the anode dislodge orbital electrons from cated on some control panels by the warning “tech- the target material, and outer shell electrons fall in to fill nique overload,” a red light, or a failure to get a green the hole created; this movement releases energy in the light indicating that the anode is ready form of x-rays • X-ray properties: Highly penetrating; invisible; travel at 5. Most modern x-ray equipment prevents overloading the speed of light (186,000 miles per second); travel in of the tube during a series of exposures and does not straight lines as waves; have diagnostic wavelengths allow additional exposures until the tube has cooled of 0.1 to 0.5 Å; travel as bundles of energy called sufficiently photons; can ionize matter; can cause fluorescence; electrically neutral • Wavelength: Distance from crest to crest or trough to trough of a sine wave KEY REVIEW POINTS • Frequency: Number of waves passing a given point per unit time Conditions Necessary for the Production of X-Rays • Wavelength and frequency are inversely proportional to each other • Short-wavelength rays are more penetrating; long- • Needed for x-ray production: Source of electrons, wavelength rays are less penetrating acceleration of electrons, sudden stoppage of electrons • X-ray emission spectrum: Collection of all different • Autotransformer: A variable transformer; operates on energies (wavelengths) of x-rays in a typical x-ray beam the principle of self-induction; allows the manipulation • Beam filtration: Removes long-wavelength rays; total of kVp and mA filtration must be at least 2.5-mm aluminum equivalent • Prereading voltmeter: Indicates the kVp that will flow • Heat units: Calculation of the total heat produced through the x-ray tube during exposure during an x-ray exposure • Timer: Regulates duration of x-ray exposure; electronic timer accurate at 1/1000 second • AEC: Ionization chamber that provides consistency of radiographic quality; placed between the patient and the image receptor • Falling load generator: Provides extremely short Fluoroscopy exposure times by taking advantage of tube heat- loading potential A. Non-digital fluoroscopy • Step-up transformer (high-voltage transformer): Operates on principle of mutual induction; steps up 1. Provides dynamic visualization of internal structures voltage, steps down current 2. Consists of an x-ray table to hold the patient, with • Rectifier: Changes AC to DC x-ray tube inside the table, the spot imaging device • Milliammeter (mA meter): Measures tube current and image intensifier (image receptors) over the table, and a monitor nearby 66 PART 1 Review and Study Guide

g. The output phosphor is smaller than the input Output phosphor phosphor, resulting in an increase in brightness called minification gain h. Total brightness gain is a product of minification gain and flux gain Glass envelope i. Total brightness gain ranges from 5000 to 20,000 and decreases as the tube ages 10. Magnification is possible only with dual-focus or Focusing lenses trifocus tubes, which result in increased patient dose 11. Varying the voltage flowing through the image- intensifier tube changes the size of the area on the Path of electrons input phosphor or photocathode being used; this results in the ability to perform magnification during Photocathode fluoroscopy 12. A second way of measuring image intensifier effi- Input phosphor ciency is by using the conversion factor 13. Conversion factor is measured as the ratio of the • Figure 4-5 Diagram of the image intensifier. luminance of the output phosphor compared with the exposure rate at the input phosphor 3. Spot imaging device allows the fluoroscopist to 14. Viewing and recording of fluoroscopic image acquire images of an area of interest as it is seen a. Image may be sent to various viewing and record- “live” on the monitor ing devices using an image distributor located 4. X-ray tube and image receptors are connected with near the output phosphor a C-arm to keep them the appropriate distance b. The signal may be sent to a television monitor for apart, regardless of the movement of the equipment viewing 5. X-ray tube for fluoroscopy is operated at 3 to 5 mA c. The fluoroscopic image may be recorded 6. Regulation of kVp and mA for fluoroscopy depends B. Digital fluoroscopy Figure( 4-6) on the part being examined 1. X-ray equipment is similar to conventional fluoros- kVp and mA determine the brightness level of the copy fluoroscopic image 2. An operating console and computer workstation are a. kVp and mA are automatically adjusted during added fluoroscopy by a process known asautomatic 3. The image intensifier may be replaced by a flat panel brightness control (ABC) image receptor similar to DR technology b. Also called automatic brightness stabilization 4. Flat panel image intensifier c. Also called automatic gain control a. Uses flat panel image receptor technology similar to 7. Visible image on the monitor is a result of image DR plates in place of conventional image intensifier intensification b. Provides better resolution of smaller anatomy 8. Image-intensifier tube converts x-ray energy into c. Allows for more variety in postprocessing visible light and then into an electronic signal that d. Some panels increase the size of the imaged area of is displayed as an image on the monitor the patient 9. Image-intensifier tube consists of the following e. May reduce patient dose in magnification mode parts (Figure 4-5) compared with image intensifier tubes a. Input phosphor: Receives exit rays from the patient f. Images are distortion-free and converts them into visible light g. Image remains constant across the entire panel b. Visible light from input phosphor strikes the 5. The x-ray beam is pulsed to keep patient dose and photocathode, a thin layer next to the input heat units at a minimum phosphor; it releases electrons in amounts directly 6. The analog signal is sent through an analog-to-digital proportional to the visible light striking it converter to convert information into numerical digi- c. The electrons are concentrated and directed tal data toward the other end of the image-intensifier 7. Viewing should take place on a high-resolution flat tube (anode) by a series of electrostatic lenses and panel monitor to take advantage of the digital capa- by 25 kVp applied through the tube bilities d. The electrons strike the output phosphor 8. Postprocessing manipulation of the image is possible e. The energy of the electrons is converted by the because the image is in digital format (subtraction is phosphors to visible light in amounts 50 to 75 an especially useful postprocessing technique, whereby times greater than at the photocathode bone and soft tissue are removed from the image) f. This increase in brightness caused by acceleration 9. “Overhead” postfluoroscopy images are usually elimi- of the electrons is called flux gain nated with digital fluoroscopy Chapter 4 Image Production 67

Analog-to-digital Digital Television Analog converter digitizes fluoroscopic Input monitor video signal video signal image phosphor y Photocathode Electrostatic Time ms lenses Output phosphor x Light ab c Beam-splitting mirror X-rays Television Electrons camera

Cine or spot-film camera • Figure 4-6 Analog and digital signals in fluoroscopy. The video signal from the television camera is analog, wherein the voltage signal varies continuously. This analog signal is sampled (a), producing a stepped representation of the analog video signal (b). The numerical values of each step are stored (c), producing a matrix of digital image data. (Courtesy Eastman Kodak Company.)

KEY REVIEW POINTS 2. These batteries are recharged by plugging the machine Fluoroscopy into an outlet 3. The batteries provide power to propel the unit and • Fluoroscopy: Provides dynamic visualization of internal operate the x-ray tube structures 4. High-frequency mobile radiographic units are smaller • X-ray tube for fluoroscopy is operated at 3 to 5 mA and provide ripple-free output • ABC: In fluoroscopy, adjustment of mA and kVp to B. Mobile fluoroscopic units are usually calledC-arms provide optimal image • Image-intensifier tube: Consists of input phosphor, 1. X-ray tube and image intensifier are located on oppo- photocathode, electrostatic lenses, output phosphor site cusps of the “C” just as in stationary fluoroscopy • Input phosphor: Converts x-ray energy to light energy 2. Mobile units are capable of providing stationary • Photocathode: Converts light energy to electron energy images (using a last-image-hold feature) and dynamic • Electrostatic lenses: Keep electron beam narrowed as it images travels toward output phosphor • Output phosphor: Converts electron energy to light 3. Mobile units are used primarily in surgery energy for viewing • Total brightness gain: Product of flux gain and minifica tion gain KEY REVIEW POINTS • Flux gain: Gain in brightness caused by acceleration of electronic beam inside image-intensifier tube • Mobile units • Minification gain: Gain in brightness caused by minifica • Mobile radiographic units are powered by rechargeable tion of the image at the output phosphor compared battery packs; x-ray output is similar to that with with the input phosphor nonmobile units • Flat panel plate similar to DR technology may be used • Mobile fluoroscopic units are generally called C-arms; in place of an image intensifier normally used in surgery • Digital fluoroscopy: Fluoroscopic signal is sent through an analog-to-digital converter enabling images to be manipulated and postprocessed; generally eliminates “overhead” images Quality Control of X-Ray–Producing Equipment

A. Quality control and assurance—not all tests listed here Mobile Radiographic and are on the certification exam; these are presented for use Fluoroscopic Units as a course study guide 1. Quality assurance: Complete program in a radiol- A. Mobile radiographic units allow radiography to be per- ogy department that addresses all aspects of quality, formed under almost any conditions including customer service, image interpretation, 1. Mobile radiographic units operate on rechargeable accuracy of diagnosis, and distribution of radiolo- battery packs gists’ reports 68 PART 1 Review and Study Guide

2. Quality control: Program that specifically addresses • Exposure linearity: Adjacent mA stations should be the safe and reliable operation of equipment within 10% of one another 3. A quality control program is required by The Joint • Exposure reproducibility: Radiation intensity of Commission sequential exposures should not vary more than 5% 4. A quality control program is the responsibility of • AECs: Tested to verify reproducibility of exposure, with phantoms used to simulate variations in patient radiologists, radiology managers, radiation physi- thickness cists, quality control technologists (sometimes a • Fluoroscopy exposure rate: Entrance skin dose should separate position and sometimes a staff radiogra- not be more than 100 mGya per minute pher’s duties; this depends on the size of the radiol- • ABC on image intensifier: Checked to ensure that ogy department) radiation dose hitting the input phosphor is constant 5. Many different tests may be performed as part of a quality control program 6. Filtration-beam quality: Tested using a digital dosim- Digital Image Acquisition eter; half-value layer measurement is required 7. Collimator/light field to radiation field alignment: Accept the challenges so that you may feel the exhilaration of victory. Must be accurate to within 2% of the source-to- image receptor distance (SID) Digital Imaging Equipment 8. Effective focal-spot size: Should be within 50% of size stated in equipment specifications A. Computed radiography (CR) (Figure 4-7) 9. KVp: Must be accurate to within 10% of the kVp 1. Radiographer selects exposure factors indicated; some sources indicate ± 3-5 kVp 2. Accurate positioning remains critical 10. Timer: Should be within 5% of the time chosen for 3. Image receptor is an imaging plate (IP) exposures over 10 ms a. Coated with a photostimulable phosphor (PSP) 11. Exposure linearity: Adjacent mA stations should be that is applied to a semirigid support layer within 10% of one another b. PSP is struck by the remnant rays exiting the 12. Exposure reproducibility: Radiation intensity of patient sequential exposures should not vary more than 5% c. Remnant rays transfer their energy to electrons in 13. AEC: Tested to verify reproducibility of exposure the phosphors, placing the electrons in a higher using phantoms to simulate variations in patient level conductive layer, where they are trapped until thickness placed in the reader 14. Fluoroscopy exposure rate: Tested with a digital d. IP can store the image for several hours; after that, dosimeter; dose should not be more than 100 mGya the energy slowly dissipates and the latent image per minute fades; plates should be processed within 8 hours 15. ABC on image intensifier: Checked to ensure that e. The x-ray exposure must fall within a range that radiation dose hitting the input phosphor is con- allows the appropriate number of x-ray photons to stant strike the CR plate

KEY REVIEW POINTS Quality Control of X-Ray–Producing Equipment Imaging Stacker plate (IP) Computer • Quality assurance: Complete program in a radiology workstation department that addresses all aspects of quality, including customer service, image interpretation, accuracy of diagnosis, and distribution of radiologists’ reports • Quality control: Program that specifically addresses the Stacker safe and reliable operation of equipment Erasure • Filtration-beam quality: Tested using a digital dosimeter; unit half-value layer measurement is required • Collimator/light field to radiation field alignment: Must Laser be accurate to within 2% of SID Image reader Laser Laser printer • Effective focal-spot size: Should be within 50% of size scanner stated in equipment specifications • Figure 4-7 The exposed IP is placed in a reader unit to release the • kVp: Must be accurate to within 10% of that chosen stored image, convert the analog image to a digital image, and send • Timer: Should be within 5% of the time chosen for the data to a computer monitor or laser printer. The reader unit also exposures over 10 ms erases the exposed IP in preparation for the next exposure. (Courtesy Fuji Medical Systems.) Chapter 4 Image Production 69

X-ray tube

Computer workstation

Laser printer

Flat panel Modified direct capture radiographic detector table • Figure 4-8 Flat panel digital detector fixed in a modified x-ray table.

4. Reader unit accepts the cassette and removes the IP so 6. Viewing of the digital image takes place on a com- that it may be scanned with a laser puter monitor, normally a flat panel LCD screen a. Laser beam scans PSPs C. Workstation monitors b. Laser scanning allows the electrons to relax into 1. Most monitors are flat panel LCD screens that are lower energy levels in the phosphors designed to reduce the effect of ambient lighting on c. As the electrons relax into lower energy levels, a the image visible blue light is emitted 2. Monitors at the technologist workstation are normally d. Blue light energy is amplified by a photomultiplier lower resolution, used to review acquired images for and then converted from analog to digital form exposure and positioning before they are sent to the and sent to the computer for processing radiologist 5. The radiographer must be very familiar with the 3. Monitors at the radiologist workstation are high reso- equipment being used, especially the manufacturer’s lution for maximum detail and better contrast resolu- terminology for exposure indicator tion 6. Viewing of the digital image takes place on a com- 4. Monitors control the brightness of the image, defined puter monitor, normally a flat panel liquid crystal as the intensity of light representing the various pixels display (LCD) screen comprising the image B. Digital radiography (DR) (Figure 4-8) 5. Brightness: The measurement of luminance of an area 1. Differs from CR by using flat panel detectors that of a radiographic image displayed on a monitor communicate directly with a computer workstation D. Imaging informatics 2. The flat panel DR systems produce an image more 1. CR and DR are part of an integrated system of images quickly than CR and written data 3. Patient throughput generally is higher than with CR a. Picture archiving and communications system 4. Flat panel DR system may use either direct or indi- (PACS) rect detectors 1. Comprises systems for image acquisition, dis- a. Direct detectors convert exit radiation energy play, network, storage directly into electrical charges, speeding image b. Digital imaging and communications in medicine construction (DICOM)—a standard protocol used for blend- b. Indirect detectors convert exit radiation energy ing PACS and various imaging modalities first to visible light via a phosphor layer and then c. HIS (hospital information system)—blends patient to electrical charges care information, reporting, and billing 5. Electrical signals from either direct or indirect detec- d. RIS (radiology information system)—used for tors are converted from analog to digital ordering procedures and reporting results 70 PART 1 Review and Study Guide

TABLE 4-1 American Registry of Radiologic Technologists (ARRT) Standard Definitions*

Term Digital Radiography includes both computed radiography and direct radiography Computed Radiography (CR) systems use storage phosphors to temporarily store energy representing the image signal. The phosphor then undergoes a process to extract the latent image. Direct Radiography (DR) systems have detectors that directly capture and read out an electronic image signal. Spatial Resolution The sharpness of the structural edges recorded in the image. Receptor Exposure The amount of radiation striking the image receptor. Brightness Brightness is the measurement of the luminance of an area in a radiographic image displayed on a monitor. It is calibrated in units of candela (cd) per square meter. Contrast Contrast is the visible difference between any two selected areas of brightness levels within the displayed radiographic image. It is determined by the processing algorithm (mathematical codes used by the software to provide the desired image appearance). The default algorithm determines the initial processing codes applied to the image data. Grayscale refers to the number of brightness levels (or gray shades) visible on an image and is linked to the bit depth of the system. Long Scale is the term used when slight differences between gray shades are present (low contrast) but the total number of gray shags is great. Short Scale is the term used when considerable or major differences between gray shades are present (high contrast) but the total number of gray shades is small. Dynamic Range The range of exposures that may be captured by a detector. Receptor Contrast The fixed characteristic of the receptor. Most digital receptors have an essentially linear response to exposure. This is impacted by contrast resolution (the smallest exposure change or signal difference that can be detected). Ultimately, contrast resolution is limited by the quantization (number of bits per pixel) of the analog-to-digital convertor. Exposure Latitude The range of exposures that produces quality images at appropriate patient dose. Subject Contrast The magnitude of the signal difference in the remnant beam as a result of the different absorption characteristics of the tissues and structures making up that part.

*From American Registry of Radiologic Technologists: Radiography examination content specifications, St. Paul, MN, 2015, ARRT. Implementation date January 2017.

e. EMR (electronic medical record), in some cases KEY REVIEW POINTS referred to as her (electronic health record)—com- Digital Imaging Equipment prehensive collection of patient information stored in a digital format; may be shared across networks; data • Digital image produced when the analog signal is may include history, medications, allergies, all types sent through an analog-to-digital converter to convert of test results including diagnostic images, vital signs information into numerical data • CR : Uses an IP made of a PSP; absorbs energy exiting the patient; IP is scanned with a laser; energy released Quality Control of Digital Equipment is converted from analog to digital for postprocessing • With CR, x-ray exposure must fall within a range that A. Initial acceptance testing: Verify equipment matches allows the appropriate number of x-ray photons to specifications strike the IP B. CR plate maintenance • Direct DR: Uses wired or wireless flat panel detectors 1. Inspect and clean IP regularly that communicate directly with a computer workstation 2. Plate erasure at least every 48 hours • DR flat panel systems produce an image more quickly than CR C. Uniformity of processing codes: Verify codes across the • Flat panel DR systems may use either direct or indirect facility detectors D. CR reader: Calibrate annually • DR direct detectors: Convert exit radiation directly into E. DR plate maintenance electrical charges, speeding image construction 1. Inspect and clean regularly • DR indirect detectors: Convert exit radiation first to visible light and then to electrical charges; uses CCD F. Monitors (charge coupled device) or CMOS (complementary 1. Clean as needed metal oxide semiconductor) 2. Use QC monitor test pattern to verify image quality, • Electrical signals from either direct or indirect detectors resolution, presence of geometric distortion are converted from analog to digital; viewed on a monitor 3. Measure luminance with a luminance meter 4. Determine presence of reflections and their sources Continued Chapter 4 Image Production 71

KEY REVIEW POINTS—cont’d should never be overexposed with the intention of correcting the resultant images in the postprocessing Digital Imaging Equipment mode (dose creep) I. Image may be printed onto film with a laser camera • Monitors may be lower resolution (technologist work J. Resolution is finer with DR than with CR because DR station) or higher resolution (radiologist workstation) • Monitors determine the brightness of the image involves less conversion of the information • Brightness : The measurement of luminance of an area K. In both CR and DR, visibility of the resolution depends of a radiographic image displayed on a monitor on the monitor being used to display the image • Imaging informatics may include PACS, DICOM, HIS, L. Changing the window level (midpoint of densities) RIS, EMR adjusts the image brightness (lighter or darker) through- • Digital equipment has its own unique set of quality control tests out the range of densities in postprocessing mode; this is a direct relationship 1. As window level increases, image brightness increases 2. As window level decreases, image brightness decreases Overview of CR and DR Image Characteristics M. Changing the window width adjusts the radiographic contrast in postprocessing mode A. Wide exposure latitude; range of exposure techniques 1. As window width narrows, contrast increases that will result in an acceptable image 2. As window width widens, contrast decreases B. Exhibit good visualization of soft tissue and bone N. Spatial frequency resolution: Level of detail or sharpness . C Digital image is composed of numerical values indicat- on the CR image ing the variety of tissue thicknesses, densities, and atomic O. Look-up table (LUT): Histogram of pixel values from numbers through which the x-ray photons are attenuated image acquisition that can be used to correct or enhance D. Digital image is composed of rows and columns called a luminance values matrix . P Beam-part-receptor alignment latitude—crucial so that 1. Matrix size equals the total number of pixels in the the software can detect collimated edges image Q. Quantum mottle (“grainy” or “noisy” image) 2. Smallest component of the matrix is the pixel (picture 1. Is a source of noise in the image element) 2. Caused by too few x-ray photons hitting the image . 3 Each pixel corresponds to a shade of gray representing receptor (normally from too low kVp) an area in the patient called a voxel (volume element) R. Artifacts may be present in digital radiography 4. Pixel density—number of pixels/mm in the image; 1. Artifacts related to the image receptor determined by pixel pitch a. Any object on the surface of the image receptor 5. Pixel pitch—space from the center of one pixel to the (e.g., hair, dust, adhesive) may result in a light area center of an adjacent pixel on the image the shape of the object; may also be E. A histogram (graphic display) is constructed to show the caused by dust on the CR plate reader rollers radiographer the distribution of pixel values (indicating . b Mishandling of the image receptor may result in low, proper, or high exposure) bending or cracks in the plate that may cause areas . F The correct processing algorithm (mathematical for- of dead pixels or a row of dead pixels; dead pixels mula) must be chosen so that the computer can are unable to display the information deposited reconstruct the image specific to the exam that was in their region of the image; dead pixel correction performed software may provide some correction G. As a digital image, the information can be manipulated c. Inadequate erasure of an image receptor, or incor- through various postprocessing steps (subtraction, edge rect erasure settings, may result in “ghosting,” the enhancement, contrast enhancement, and black/white appearance of anatomy imaged on the previous reversal) exposure (also called image lag) 1. Subtraction: Removal of superimposed or unwanted . 1 Thiscan occur more often with DR plates as structures from the image opposed to CR cassettes since there is usually a 2. Contrast enhancement: Altering of image to display shorter time period between exposures using DR varying brightnesses d. Excessive backscatter radiation may result in the 3. Edge enhancement: Improves visibility of small, high- electronics of the DR plate being imaged and visu- contrast areas alized, even with additional lead foil backing on 4. Black/white reversal: Reversal of the gray scale in the the plate image . e Malfunctioning rollers in the CR plate reader may . H Postprocessing can compensate for overexposures or result in vertical or horizontal lines across the image underexposures of considerable degree (−100% to +500%) . f A CR imaging plate that “stutters” or pauses while 1. Because radiographers comply with the as low as in the reader may result in wavy lines across the reasonably achievable (ALARA) concept, patients image 72 PART 1 Review and Study Guide

g. Incorrectly oriented grids may cause a moiré pattern • Detective quantum efficiency (DQE): The efficiency with on the image; seen more often with low ratio grids which the digital system converts an x-ray signal to a h. Digital imaging plates are extremely sensitive to useful diagnostic image scatter radiation; control of scatter is critical • Digital image artifacts: May be related to image receptor 2. Artifacts related to software issues, software, or technical errors • Dynamic range: Image receptor’s ability to acquire the a. Overprocessing the digital image may lead to loss chosen exposure of information • Detector element (DEL): Smallest resolvable area of the b. Overcompression of the image may result in a loss image receptor of information in the image • Modulation transfer function: Ability of the digital system 3. Artifacts related to technical errors to accurately record spatial frequencies • Automatic rescaling (Auto Ranging, rescaling, scaling, a. Improper collimation may lead to exposure field normalization): Software ability to produce images with recognition error and histogram analysis errors; the consistent brightness and contrast image may appear too light, too dark, or too noisy • Detector size (field of view): Area of the imaging device b. Misalignment of the exposure field may lead to that is used to acquire the useful image exposure field recognition error and histogram • Quantization: Ability to assign a value to each pixel corresponding to the gray shade determined by its bit analysis errors; the image may appear too light, too depth dark, or too noisy • Stitching: Use of software to connect multiple images into one image KEY REVIEW POINTS • Region of interest: Identifying a specific anatomic area on a digital image CR and DR Image Characteristics with Related • Dead pixel correction: Assigning a value to a dead pixel Definitions based on the values of adjacent pixels • Flat fielding: Preprocessing calibration techniques used • Wide exposure latitude; better visualization of soft to make the response of the image receptor uniform tissue and bone • Digital image: Composed of rows and columns called a matrix Properties of the Digital Image • Pixel: Picture element; smaller part of a digital image; is a shade of gray representing a voxel Receptor Exposure • Pixel density: Number of pixels/mm in the image; determined by pixel pitch Controlling and Influencing Factors • Voxel: Volume element; an area of tissue in the patient A. mAs • Histogram (graphic display): Shows the radiographer 1. Controls the number of electrons passing from cath- the distribution of pixel values (indicating low, proper, or high exposure) ode to anode in the x-ray tube • Processing algorithm (mathematical formula): Used by 2. Controls the quantity of x-rays produced at the anode the computer to reconstruct the image specific to the 3. Controls the amount of radiation exiting the x-ray tube exam that was performed a. This is a directly proportional relationship • Postprocessing: Subtraction, edge enhancement, b. As mAs is increased, receptor exposure increases in contrast enhancement, black/white reversal • Subtraction: Removal of superimposed or unwanted the same amount structures from the image c. As mAs is decreased, receptor exposure decreases • Contrast enhancement: Altering of image to display in the same amount varying brightnesses 4. Directly controls the number of x-ray photons that • Edge enhancement: Improves visibility of small, high- emerge from the patient as exit rays contrast areas • Black/white reversal: Reversal of the gray scale in the image 5. Directly controls the number of x-rays that eventually • Window level (midpoint of the image densities): Adjusts strike the image receptor as exit rays the image brightness throughout the range of densities; B. kVp this is a direct relationship 1. Directly controls the energy or quality of the x-rays • Window width: Adjusts the image contrast (gray scale) produced in postprocessing mode; this is an inverse relationship • Spatial frequency resolution: Level of detail or sharpness a. As the kVp increases, a greater potential difference on the CR image exists between the cathode and the anode • LUT: Histogram of brightness level values from image b. As the potential difference increases, the electrons acquisition that can be used to correct or enhance from the cathode strike the anode in greater num- luminance values bers and with greater energy • Quantum mottle (“grainy” or “noisy” image): Source of noise in the image; caused by too few x-ray photons c. This results in an increased level of production of hitting the image receptor short-wavelength, high-energy radiation • Signal-to-noise ratio (SNR): Comparison of the useful 2. Directly affects receptor exposure, although not in a signal to the presence of noise; high SNR results in a directly proportional relationship higher quality image a. As kVp increases, receptor exposure increases b. As kVp decreases, receptor exposure decreases Chapter 4 Image Production 73

c. Governed by the 15% rule (an increase in kVp of F. Anatomy and pathology 15% doubles receptor exposure; a decrease in kVp 1. Anatomy affects receptor exposure through its varia- of 15% halves receptor exposure) tion of atomic number, tissue thickness, and tissue 3. Determines the penetrating ability of the x-ray beam density a. As kVp is increased, wavelength decreases, and 2. Pathologic changes affect receptor exposure by alter- x-rays become more penetrating ing tissue integrity, atomic number, tissue density, b. As kVp is decreased, wavelength increases, and and tissue thickness (see Chapter 5 for specific patho- x-rays become less penetrating logic conditions and their effects on radiographic 4. Penetrating ability of the x-rays also determines the technique) number of x-rays exiting the patient to strike the G. Anode heel effect image receptor 1. X-ray intensity varies along the longitudinal axis of C. Distance the x-ray beam 1. Inverse square law a. Receptor exposure is greater near the cathode end a. Beam intensity (and ultimately receptor exposure, of the x-ray beam which is a function of beam intensity) is governed b. Receptor exposure is less near the anode end of by the inverse square law the x-ray beam because x-rays are absorbed by the b. Inverse square law: Intensity of the x-ray beam is “heel” of the anode inversely proportional to the square of the distance 2. Thicker anatomy should be placed under the cathode between the source of x-rays and the image receptor side of the x-ray tube to take advantage of the anode c. Expressed as: old intensity/new intensity = new heel effect SID2/old SID2 H. Filtration d. This equation describes changes in beam inten- 1. Negligible effect on receptor exposure; its purpose is sity (and receptor exposure, which is a function primarily for radiation protection of beam intensity) when SID is changed and no 2. Radiation protection is due to the reduction in the changes are made in exposure technique number of soft, long-wavelength rays being absorbed e. If SID is doubled, intensity (receptor exposure) in the patient decreases four times; if distance is halved, intensity 3. Has an impact on contrast because the average wave- (receptor exposure) increases four times length of the filtered beam is shorter than the nonfil- f. Variation in intensity is the result of the diver- tered beam gence of the x-ray beam as it travels through space 4. Compensating filters even out density of irregular 2. Exposure maintenance formula anatomy a. Expressed as: old mAs/new mAs = old SID2/new SID2 b. Used to calculate changes in mAs needed to main- KEY REVIEW POINTS tain receptor exposure when dealing with a change in SID Receptor Exposure c. If SID is doubled, mAs must be increased four times to maintain the same receptor exposure as • Receptor exposure: The intensity of radiation striking that of an image taken at the old distance; if dis- the image receptor; it directly determines the quality of the digital image tance is halved, mAs must be decreased four times • Receptor exposure is directly controlled by mAs— to maintain the same receptor exposure as that of mAs controls the current through the x-ray tube and, a radiograph taken at the old distance consequently, the number of x-rays produced at the D. Grids anode 1. Decrease the amount of scatter radiation striking the • kVp: Controls the energy of x-rays produced; also has a direct impact on receptor exposure, although not image receptor proportional; governed by the 15% rule 2. Receptor exposure decreases when grids are used, • SID: Affects receptor exposure through the inverse unless mAs is increased to compensate for the loss of square law scatter fog • Grids: Absorb scatter radiation; this has an impact on E. Beam restriction the receptor exposure • Beam restriction: Limits the size of the x-ray beam; 1. Decreases receptor exposure by limiting the size of the affects receptor exposure by reducing the amount of x-ray beam, unless mAs are increased to compensate scatter produced 2. Decreases receptor exposure by limiting the area of • Anatomy and pathology: Affect receptor exposure the patient being struck by x-rays through variations of atomic number, tissue thickness, 3. Reduces the amount of scatter radiation being pro- and tissue density • Anode heel effect: Has some effect on receptor duced, reducing receptor exposure caused by fog; exposure when a large field is being exposed necessary for proper image processing with digital imaging 74 PART 1 Review and Study Guide

Contrast c. Tissue thickness: As tissue thickness increases, contrast decreases owing to Compton interaction Contrast Overview d. Use of a contrast agent increases contrast owing to A. Contrast is the visible difference between two selected photoelectric effect areas of brightness in the displayed radiographic e. Causes differential absorption of x-ray photons, image which results in contrast B. Gray scale is the number of gray shades, or brightness B. Contrast resolution levels, visible on an image 1. Ability of the imaging system to distinguish the C. Long-scale contrast indicates small differences between smallest change in exposure or signal gray shades; large number of gray shades present 2. Provides visibility of small objects having similar D. Short-scale contrast indicates much difference between shades of gray gray shades, few gray tones present, more black-and- 3. Controlled by bit depth, the number of bits per pixel white image (the larger the bit depth, the greater the number of E. Subject contrast—refers to the differences in the rem- levels of gray possible in an image) nant beam secondary to the differential absorption of C. Grids the x-ray beam by the structures in the body 1. Reduce the amount of scatter reaching the image F. Contrast resolution—the smallest change in signal that receptor can be detected by the receptor 2. Less scatter fog results in fewer gray tones, which increases contrast Controlling and Influencing Factors D. Beam restriction A. Subject contrast 1. Limits area being irradiated 1. kVp directly controls the differential absorption of 2. Produces less scatter by reducing the number of the x-ray beam in the body (Figure 4-9) Compton interactions taking place a. As kVp is increased, the shorter-wavelength rays 3. Less scatter fog reduces the number of gray tones on more uniformly penetrate anatomic parts to the radiograph, increasing contrast become part of the remnant beam striking the E. Filtration (Figure 4-10) image receptor 1. As filtration is increased, beam becomes harder (aver- b. As kVp is decreased, there is greater absorption age photon striking the patient has shorter wave- of lower energy rays by the anatomic parts due to length) photoelectric interaction, changing the remnant 2. Contrast decreases as filtration increases beam striking the image receptor 2. Anatomy and pathology: Controls contrast with variations in the following: a. Atomic number: Higher atomic number indi- KEY REVIEW POINTS cates increase in contrast owing to photoelectric Contrast effect b. Tissue density: As tissue density increases, contrast • Contrast is the visible difference between two selected decreases owing to Compton interaction areas of brightness in the displayed radiographic image • Contrast resolution is the ability of the imaging system to distinguish the smallest change in exposure or signal; controlled by bit depth, the number of bits per pixel (the Primary x-ray photon larger the bit depth, the greater the number of levels of gray possible in an image) X-ray photon • High contrast: Few gray tones, mainly black-and-white penetrates the image; may also be referred to as short-scale contrast; part to help produced at lower kVp form the image • Low contrast: Many gray tones on image; may also be X-ray referred to as long-scale contrast; produced at higher photons X-ray photon kVp absorbed that becomes • Subject contrast is controlled by kVp—kVp controls by part scatter radiation differential absorption of the x-ray beam by the body because of its control of x-ray beam energy; also con trolled by anatomy and pathology through variations of atomic number, tissue thickness, and tissue density; produced by photoelectric effect Image • Grids: Reduce the amount of scatter reaching the receptor image receptor, increasing contrast • Figure 4-9 As the primary beam interacts with the anatomic part, • Beam restriction: Limits area being irradiated, so less photons are absorbed, scattered, and transmitted. The differences in scatter is produced, and contrast is increased the absorption characteristics of the anatomic part create an image that structurally represents the anatomic part. Chapter 4 Image Production 75

X-ray tube Target Target angle angle

Collimator

15° Anode 10° Anode target target

Inherent filtration

Thinned wall of glass envelope of x-ray tube insert Actual focal Actual focal spot size spot size Insulating oil

Exit Aluminum port added filtration Effective focal Effective focal spot size spot size Thin metal A B mirror of collimator • Figure 4-11 The line focus principle states that a large target angle offering produces a large effective focal spot size (A) and that a small target X-ray additional angle produces a small effective focal spot size (B). Both actual focal beam filtration spot sizes are the same, meaning they can withstand the same heat loading from the same exposure factors. • Figure 4-10 Aluminum added filtration is shown at the port of the x-ray tube. The inherent filtration of the glass envelope and the oil and the collimator mirror are shown. E. Focal-spot size (Figure 4-11) Spatial Resolution 1. Focal-spot size is most often chosen by the x-ray machine itself; it is not usually controlled by the A. Sharpness of the structural edges in the image; smallest radiographer detail that can be detected 2. If size is controllable, use small focal spot when B. May be described as the geometric representation of the possible part being imaged 3. Use of large focal spot decreases sharpness in the C. May also be referred to as detail sharpness, definition, image as a result of x-rays emanating from a larger image resolution area of the anode; adds to image blur D. Nyquist frequency: The highest spatial resolution that can F. Motion be recorded; controlled by pixel pitch 1. Any motion results in image blur and subsequent loss of recorded detail Controlling and Influencing Factors 2. Motion may be caused by the following A. Pixel size—smaller pixels provide greater spatial resolution a. Patient motion (voluntary and involuntary) B. Pixel pitch—space between pixels; less space between b. X-ray tube motion pixels provides greater spatial resolution c. Excessive motion from reciprocating grid C. Object-to-image receptor distance (OID) 1. Distance from the anatomic part being imaged to the image receptor KEY REVIEW POINTS 2. Shortest possible OID should be used Spatial Resolution 3. Increased OID causes magnification of the image, resulting in loss of recorded detail • Spatial resolution: sharpness of the structural edges in D. Source-to-image receptor distance (SID) the image; smallest detail that can be detected 1. Distance from the source of radiation to the image • May also be referred to as detail sharpness, definition, receptor image resolution • Controlled by pixel size and pixel pitch 2. Longest practical SID should be used • Influenced by SID, OID, focal-spot size, motion 3. Shorter SID causes magnification of the image, resulting in loss of sharpness 76 PART 1 Review and Study Guide

Distortion A. Any geometric misrepresentation of an anatomic structure on an image receptor B. Two types of distortion: size and shape Factors Controlling Distortion A. Size 1. Magnification 2. Caused by excessive OID 3. Caused by insufficient SID 4. Causes anatomic structure to appear larger on the image than in reality B. Shape (Figure 4-12) 1. Elongation a. Causes anatomic structure to appear longer than in reality b. Caused by improper tube, part, or image receptor angulation or alignment A B C c. Caused by angulation along the long axis of the part 2. Foreshortening • Figure 4-12 A, No distortion. B, Foreshortened. C, Elongated. a. Causes anatomic structure to appear shorter than in reality b. Caused by improper tube, part, or image receptor Absorbed angulation scattered c. Caused by angulation against the main axis of the Transmitted photon part photon

Unabsorbed KEY REVIEW POINTS scattered photon Distortion

• Distortion : Any misrepresentation of an anatomic structure on an image receptor that alters its size and/ Lead or shape strip • Size distortion: Magnification; caused by excessive object-to-image distance (OID) or insufficient source-to- image distance (SID) Radiotransparent • Shape distortion: Elongation or foreshortening spacer • Elongation: Causes anatomic structure to appear longer than in reality; caused by improper tube, part, or film Image angulation or alignment, with angulation along the long receptor axis of the part • Foreshortening: Causes anatomic structure to appear • Figure 4-13 Ideally, grids would absorb all scattered radiation and shorter than in reality; caused by improper tube, part, or allow all transmitted photons to reach the image receptor. In reality, film angulation or alignment, with angulation against the however, some scattered photons are allowed to pass through to the main axis of the part IR, and some transmitted photons are absorbed.

2. Generally used when part thickness is 10 cm or Grids greater or when greater than 60 kVp is used B. Construction A. Use 1. Lead strips separated by aluminum interspacers 1. Reduce the amount of scatter radiation reaching the 2. Grid ratio image receptor a. Grid ratio is the height of the lead strips divided a. Scatter travels in divergent paths compared with by the distance between the lead strips: grid ratio image-producing rays (Figure 4-13) = H/D b. More likely to be absorbed in the grid b. Ratios range from 4:1 to 16:1 Chapter 4 Image Production 77

Convergent point

Convergent line

Crossed focused grid • Figure 4-16 Imaginary lines drawn above a crossed focused grid from each lead line meet to form a convergent point.

f. Focal range is stated on the front of the grid 3. Crossed grids (Figure 4-16) • Figure 4-14 Imaginary lines drawn above a linear focused grid from a. Also called crosshatch grids each lead line meet to form a convergent line. b. Consist of two linear grids placed perpendicular to each other c. Superior scatter cleanup d. Allow no angulation of x-ray beam Focal Convergent e. Require perfect positioning and centering range line or point D. Grid characteristics 1. Contrast improvement factor a. Measure of ability of a grid to increase contrast b. Expressed as the ratio of the contrast with a grid to the contrast without a grid 2. Grid selectivity Grid a. Expressed as the ratio of primary radiation trans- Film mitted through the grid to secondary radiation transmitted through the grid • Figure 4-15 The convergent line of a focused grid falls within a focal range. b. The higher the grid frequency and grid ratio, the more selective the grid c. High selectivity indicates high efficiency of scatter 3. Grid frequency cleanup a. Number of lead strips per inch (or centimeter) 3. Grid conversion factor (GCF) b. As grid frequency increases, lead strip thickness a. Also called Bucky factor decreases and becomes less visible b. Amount of exposure increase necessary to com- c. Ranges from 60 to 150 lines per inch pensate for the absorption of image-forming rays C. Grid types and scatter in the cleanup process 1. Linear c. Used to indicate the increase in mAs needed when a. Lead strips are parallel to one another converting from nongrid to grid status (multiply b. X-ray tube may be angled along the length of the mAs by GCF) grid without cutoff d. Used to indicate the decrease in mAs when con- c. Grid cutoff: Decreased density along the periphery verting from grid to nongrid status (divide mAs by of the image caused by absorption of image-form- GCF) ing rays e. Factors used at 120 kVp—5:1 grid, 2; 6:1 grid, 3; d. Used primarily with large SID or small field 8:1 grid, 4; 12:1 grid, 5; 16:1 grid, 6 2. Focused grids (Figures 4-14 and 4-15) E. Grid motion a. Lead strips are angled to coincide with divergence 1. Stationary grids of x-ray beam a. Do not move during the exposure b. Used within specific ranges of SID b. Grid lines may be seen c. Grid radius: Distance at which focused grid may 2. Moving grids be used (also called focal distance or focal range) a. Reciprocate (move back and forth) during expo- d. Focal range is wide for low-ratio grids sure e. Focal range is narrow for high-ratio grids b. Eliminate the visibility of grid lines 78 PART 1 Review and Study Guide

c. Grid must begin moving just before the exposure • Grid ratio: The height of the lead strips divided and continue until just after the exposure to blur by the distance between the lead strips: grid ratio = grid lines. H/D F. Grid errors: Focused grids • Grid frequency: Number of lead strips per inch (or 1. Upside down centimeter) • Linear grids: Lead strips are parallel to one another a. Result is normal density in the middle of the • Focused grids: Lead strips are angled to coincide with radiograph with decreased density on the sides divergence of the x-ray beam b. Focused grid must be placed with labeled tube side • Grid cutoff: Decreased density along the periphery facing x-ray tube of the film caused by absorption of image-forming 2. Off-level rays • Grid radius: Distance at which focused grid may be a. Result is image-forming rays absorbed all across used (also called focal distance or focal range) the radiographic field, with cutoff (decreased den- • Contrast improvement factor: Measure of grid’s ability sity) visible over the entire radiograph to enhance contrast b. Grid must be perpendicular to the central ray • Grid selectivity: Expressed as the ratio of primary 3. Lateral decentering radiation transmitted through the grid to secondary radiation transmitted through the grid a. Central ray does not strike the grid in the center • GCF: Amount of mAs exposure increase necessary to b. Cutoff visible, more to one side of the radiograph compensate for the absorption of image-forming rays 4. Grid-focus decentering and scatter in the cleanup process (also called Bucky a. Violation of the grid radius when a focused grid is factor) used • GCFs: At 120 kVp—5:1 grid, 2; 6:1 grid, 3; 8:1 grid, 4; 12:1 grid, 5; 16:1 grid, 6 b. Normal density in the middle of the radiograph • Stationary grids: Do not move during the exposure with cutoff visible on the sides • Moving grids: Reciprocate (move back and forth) during G. Air gap technique exposure; eliminate the visibility of grid lines 1. Uses increased OID • Upside-down grid: Result is normal density in the 2. Increased OID allows scatter (which travels in widely middle of the radiograph with decreased density on the sides divergent paths) to exit the patient and miss the • Off-level grid: Result is image-forming rays absorbed image receptor all across the radiographic field, with cutoff (decreased 3. Example: Lateral cervical spine density) visible over the entire radiograph a. Distance from spine to shoulder causes gap • Lateral decentering: Cutoff visible, more to one side of b. Eliminates need for grid (gap is similar to using a the radiograph • Grid-focus decentering: Normal density in the middle of 10:1 grid) the radiograph with cutoff visible on the sides c. Use of grid with air gap increases patient dose and is unnecessary H. Radiographic quality and grids 1. Produce higher contrast by absorbing Compton scatter rays, which produce fog if they strike the image receptor

KEY REVIEW POINTS Grids

• Use of grids reduces the amount of scatter radiation reaching the film • Construction: Lead strips separated by aluminum interspacers Chapter 4 Image Production 79

TABLE 4-2 Variables and Their Effects on Photographic and Geometric Properties of the Radiographic Image

Photographic Properties Geometric Properties Radiographic Variables Receptor Exposure Contrast Spatial Resolution Distortion

↑ mAs* ↑ 0 0 0 ↓ mAs ↓ 0 0 0 ↑ kVp ↑ ↓ 0 0 ↓ kVp ↓ ↑ 0 0 ↑ SID ↓ 0 ↑ ↓ ↓ SID ↑ 0 ↓ ↑ ↑ OID† ↓ ↑ ↓ ↑ ↓ OID ↑ ↓ ↑ ↓ ↑ Grid ratio ↓ ↑ 0 0 ↓ Grid ratio ↑ ↓ 0 0 ↑ Collimation ↓ ↑ 0 0 ↓ Collimation ↑ ↓ 0 0 ↑ Focal-spot size 0 0 ↓ 0 ↓ Focal-spot size 0 0 ↑ 0 ↑ Central ray angle ↑ 0 ↓ ↑

↑, Increased effect; ↓, decreased effect; 0, no effect; OID, object-to-image receptor distance; SID, source-to-image receptor distance. *The mAs has no significant effect on contrast as long as densities remain within diagnostic range. †The amount of OID needed to affect contrast depends on the type of anatomic part being imaged. From Fauber TL: Radiographic imaging and exposure, ed 4, St. Louis, 2012, Mosby.

Because this chapter covers two very large topics, 100 review questions on each topic are presented here:

Review Questions

Review Questions for X-ray Equipment Operation c. Electromagnetic bursts d. 1. In many cases, digital fluoroscopy eliminates which of Photons 5. the following? What is atomic mass? a. a. The need for a radiographer The number of protons plus the number of neu- b. Postprocedure “overhead” images trons b. c. Image acquisition The number of photons c. d. Accurate positioning The number of electrons d. 2. What is the smallest particle of an element that retains The number of protons plus the number of elec- the characteristics of the element? trons 6. a. Mole What device may be used to ensure consistency of b. Atom radiographic quality from one exposure to the next? a. c. Molecule Electronic timer b. d. Quark Step-up transformer c. 3. In digital fluoroscopy, the image must be turned into Automatic exposure control d. digital form by what device? High-frequency generator 7. a. Digital-to-analog converter When a predetermined level of ionization is reached b. Flux capacitor in the ionization chamber, what does the machine do? a. c. Analog-to-digital converter The unit shuts off as a result of a malfunction b. d. DVD-ROM The maximum allowable time has been reached c. 4. X-rays travel as bundles of energy called: The highest allowable dose to the patient has been a. Energy waves reached d. b. Phasers The exposure is terminated 80 PART 1 Review and Study Guide

8. What type of x-ray machine uses a continually c. Size of the patient decreasing mA for the shortest times possible? d. The fact that they are a form of electromagnetic a. Ionization chamber radiation b. Portable 19. Wavelength and frequency are: c. C-arm a. Directly proportional to each other d. Falling load generator b. Inversely proportional to each other 9. What type of current is required for proper operation c. Inversely proportional to the square of their dis- of the x-ray tube? tance a. Direct d. Unrelated to each other b. Falling load 20. The x-ray beam changes as it travels through the c. Alternating patient by a process called: d. Fluctuating a. Filtration 10. The law stating that the outer shell of an atom can b. Attenuation contain no more than eight electrons is called: c. Electrification a. Ohm’s law d. Annihilation b. Octet rule 21. The intensity of radiation is inversely proportional to c. Octagon rule the square of the distance between the source of radia- d. Electron binding energy tion and the person receiving it. This describes the: 11. Examples of particulate radiation are: a. Square law a. X-rays, gamma rays, and cosmic rays b. Reciprocity law b. Helium nuclei and beta particles c. Inverse square law c. Electrons, protons, and meteorites d. Octet law d. X-rays and quarks 22. As radiation strikes matter: 12. Electromagnetic radiation travels: a. The energy of the rays is destroyed a. In waves along a straight path b. The energy of the rays is increased as they acquire b. In circles the energy of the atoms c. Back and forth c. The energy is transferred to the atoms according to d. As electrons in waves along a straight path the law of conservation of energy 13. The latest digital fluoroscopic units use: d. The energy is converted to matter according to a. Nonionizing radiation Einstein’s theory b. CR cassettes 23. Choose all of the following statements that are accu- c. Conventional image intensifiers rate regarding electrostatic charges. d. Flat panel plates similar to DR a. Electrostatics is the study of electric charges at rest 14. At what speed do x-rays travel? b. The movement of electrons from one object to a. The speed of light—186,000 miles per hour another is called ionization b. The speed of the incident electrons—93,000 miles c. Like charges attract, and unlike charges repel per second d. Electrostatic charges concentrate on a conductor c. The speed of light—186,000 miles per second in the area of greatest curvature d. Infinite speed e. Friction, contact, and induction are methods of 15. Waves of radiation are called: ionization a. Sine waves 24. Choose all of the following that are accurate (choose 6): b. Strong waves a. A magnetic field always surrounds an electrical c. Signal waves charge in motion d. Current waves b. Current flows back and forth in AC 16. Wavelength is defined as the distance from: c. Current flows in one direction in DC a. The x-ray tube to the patient d. The volt is the unit of electrical current b. The cathode to the anode e. A conductor allows the flow of electrons c. The bottom of a wave to the top f. The ampere is the unit of electromotive force d. Peak to peak of the wave g. The volt is the unit of potential difference 17. Frequency is defined as: h. The path of electrical current is called thecircuit a. Synonymous with wavelength 25. Electromagnetic induction is the process of causing b. The number of waves passing a point per unit time an electrical current to flow in a conductor: c. The number of waves striking the patient a. When it is placed in contact with another conductor d. The number of exposures needed during an exam b. When it is placed in contact with an insulator 18. The speed of x-rays is based on: c. When it is placed in contact with a superconductor a. mAs d. When it is placed in the magnetic field of another b. kVp conductor Chapter 4 Image Production 81

26. The two types of electromagnetic induction are: c. Step-down transformer a. Autoinduction and mutual induction d. Filament transformer b. Self-induction and mutual induction 36. What is the transformer used to boost voltage to kilo- c. Generated induction and self-induction voltage levels called? d. Current induction and voltage induction a. Autotransformer 27. Self-induction is used in the operation of what device? b. Step-down transformer a. Step-up transformer c. Step-up transformer b. Autotransformer d. Low-voltage transformer c. Step-down transformer 37. Voltage coming to the x-ray machine is kept constant d. Electronic timer through the use of a(n): 28. The strength of the magnetic fields in a transformer is a. Autotransformer increased by: b. Step-down transformer a. Coiling the wires and placing them in adjoining c. Rectifier machines d. Line voltage compensator b. Coiling the wires and letting their magnetic fields 38. A step-down transformer: overlap a. Steps down voltage c. Keeping the wires very straight, increasing their b. Steps down current effectiveness c. Steps up voltage d. Replacing the wires with diodes d. Steps up resistance 29. Electricity is supplied to the imaging department by 39. Where does thermionic emission occur? a: a. Step-down transformer a. Motor b. Rectifier b. Rectifier c. Cathode c. Generator d. Timer d. Voltmeter 40. Which of the following devices is prereading? 30. The electricity provided to the radiology department a. Step-down transformer is: b. Rectifier a. 110 Hz or 220 Hz DC c. Timer b. 110 Hz or 220 Hz DC d. kVp meter c. 60 Hz AC 41. Which device reduces voltage and provides current to d. 60 Hz DC produce an electron cloud or space charge at the fila- 31. The electricity provided to the radiology department ment? operates at: a. Step-down transformer a. 120 pulses per second b. Rectifier b. 60 pulses per second c. Cathode c. 110 pulses per second d. Timer d. 220 pulses per second 42. Which device is electronic, with a setting as low as 32. High-frequency power: 0.001? a. Is less effective than single-phase power a. Step-down transformer b. Has almost no ripple b. Rectifier c. Has more ripple than three-phase power c. Cathode d. Is yet unproved d. Timer 33. The primary advantage of three-phase power is that: 43. What changes AC to DC? a. Voltage drops to zero only 6 times per second a. Step-down transformer b. Voltage drops to zero only 12 times per second b. Rectifier c. Voltage never drops to zero c. Cathode d. Voltage is always at peak value d. Timer 34. A variable transformer that is used to select kVp for 44. Which of the following is surrounded by a negatively the x-ray circuit is the: charged focusing cup? a. Step-up transformer a. Step-down transformer b. Autotransformer b. Rectifier c. Step-down transformer c. Filament d. Rectifier d. Timer 35. A transformer that has more turns in the secondary 45. Which of the following is composed of solid-state coil than in the primary coil is called a: silicon-based diodes? a. Step-up transformer a. Step-down transformer b. Solenoid b. Rectifier 82 PART 1 Review and Study Guide

c. Cathode 56. Which of the following is located between the patient d. Timer and the image receptor? 46. What regulates the duration of x-ray production? a. Anode a. Step-down transformer b. mA meter b. Rectifier c. Ionization chamber c. Cathode d. Falling load generator d. Timer 57. The filament is kept warm by: 47. What is located in the x-ray circuit between the high- a. A standby current from the time the x-ray machine voltage transformer and the x-ray tube? is turned on a. Step-down transformer b. Insulating oil b. Rectifier c. Lead housing c. Cathode d. Current produced only during exposures d. Timer 58. Activating the rotor: 48. Which of the following measures tube current? a. Accelerates a procedure a. Anode b. Reduces tube life b. mA meter c. Keeps it oiled c. Ionization chamber d. Keeps the cooling fan activated d. Falling load generator 59. When making an exposure, the radiographer 49. What device spins at 10,000-12,000 rpm? should: a. Anode a. Hold the rotor for several seconds before pressing b. mA meter “expose” c. Ionization chamber b. Activate the rotor and exposure switch in one con- d. Step-up transformer tinuous motion 50. What device uses maximum heat storage ability of the c. Begin the rotor while a student is still positioning tube to deliver mAs? the patient a. Anode d. Activate the rotor while estimating how fast the b. mA meter anode is spinning c. Ionization chamber 60. The process of thermionic emission causes: d. Falling load generator a. Electrons to boil off the anode 51. What is the source of bremsstrahlung and characteris- b. The anode to spin tic rays? c. The cathode to cool quickly a. Anode d. Electrons to boil off the filament b. mA meter 61. The force with which the electron stream passes from c. Falling load generator cathode to anode is a result of _____ passing through d. Step-up transformer the x-ray tube. 52. What device increases voltage approximately 500 a. Current times? b. Kilovoltage a. Anode c. Tungsten b. mA meter d. Heat c. Ionization chamber 62. Heat is produced in the x-ray tube as: d. Step-up transformer a. Electrons break apart while striking the anode 53. What is the most commonly used AEC? b. Electrons interact with the target material a. Phototimer c. The anode stops spinning b. mA meter d. The rectifier operates c. Ionization chamber 63. Most of the energy conversion in the x-ray tube pro- d. Falling load generator duces: 54. What device always delivers the shortest exposure a. X-rays time possible? b. Light a. Anode c. Heat b. mA meter d. Current c. Ionization chamber 64. X-rays are produced as incident electrons are slowed d. Falling load generator going past the nuclei of target atoms by a process 55. What device is turned by a rotor? called: a. Anode a. Classical b. mA meter b. Photoelectric c. Ionization chamber c. Bremsstrahlung d. Step-up transformer d. Compton Chapter 4 Image Production 83

65. X-rays are produced as incident electrons collide b. Total filtration must remove all soft rays from the with inner shell electrons in target atoms by a process beam called: c. Total filtration (added + compensating) must not a. Characteristic be less than 2.5-mm aluminum equivalent b. Photoelectric d. Total filtration (not less than 2.5-mm alumi- c. Bremsstrahlung num equivalent) = inherent filtration (glass d. Compton envelope, tube housing, oil) + added filtration 66. What percentage of energy in the x-ray tube is con- (aluminum) verted to x-rays? 73. Calculating heat units for three-phase, 12-pulse equip- a. 99% ment requires the use of _____ as a constant; calcu- b. 75% lating heat units for single-phase equipment requires c. 1% the use of _____ as a constant; calculating heat units d. 100% for three-phase, 6-pulse equipment requires the use of 67. Choose all that are properties of x-rays (choose 6): _____ as a constant. a. Electrically negative a. 1.0, 1.35, 1.41 b. Affect film emulsion b. 1.35, 1.0, 1.41 c. Scatter and produce secondary radiation c. Calculating heat units does not require the use of d. Invisible to the human eye a constant because all x-rays possess the same ion- e. Travel at the speed of light (186,000 miles per izing potential hour) d. 1.41, 1.0, 1.35 f. Possess wavelengths between 1 Å and 5 Å 74. When a quality control test is performed to ensure g. Travel in bundles of energy called photons that the penetrating ability of the x-ray beam is accu- h. Can ionize matter and gases rate, the result must be within what amount of the i. Can be focused by collimators control panel setting? j. Cause phosphors to fluoresce a. 2% of SID 68. The x-ray beam is: b. 4% a. Heterogeneous—all rays possess the same energy c. 10% b. Homogeneous—all rays possess the same energy d. 50% c. Monoenergetic—all energies correspond to the 75. The primary type of grid used in diagnostic imaging kVp is: d. Heterogeneous or polyenergetic—consisting of a. Crosshatch many different energies (wavelengths) b. Parallel 69. The x-ray emission spectrum consists of: c. Rhombic a. Brems and characteristic rays d. Focused b. Discrete spectrum (produced by brems rays) and 76. The portion of the image-intensifier tube that con- continuous spectrum (produced by characteristic verts electron energy to visible light is the: rays) a. Output phosphor c. Discrete spectrum (produced by characteristic b. Photocathode rays) and continuous spectrum (produced by c. Input phosphor brems rays) d. Detector element d. X-rays and electrons, both part of the electromag- 77. The portion of the image-intensifier tube that con- netic spectrum verts visible light to electrons is the: 70. The primary purpose of filtration is: a. Output phosphor a. Radiation protection b. Photocathode b. Removal of short-wavelength (soft) rays c. Input phosphor c. Hardening the beam for imaging d. Anode d. Removal of long-wavelength (hard) rays 78. The input phosphor of the image-intensifier tube 71. The amount of material needed to reduce the inten- converts: sity of the beam by 1/10 is called: a. Electron energy to x-ray energy a. Half-value layer b. X-rays and heat to visible light b. Tenth-value layer c. X-ray energy to visible light c. Total filtration d. X-ray energy to an electronic image d. Inherent filtration 79. Total brightness gain achieved using an image intensi- 72. Which of the following statements regarding filtra- fier equals: tion is true? a. Flux gain times minification gain a. Total filtration must not be less than 2-mm alumi- b. Diameter of input phosphor times diameter of num equivalent output phosphor 84 PART 1 Review and Study Guide

c. Intensification factor—brightness without an 88. kVp must be accurate to within: image intensifier divided by brightness with an a. 1 of the amount on the control panel setting image intensifier b. 5% of the control panel setting d. Total light emitted at the photocathode c. 2% of SID 80. Single-phase, full-wave rectification produces: d. 10% of the control panel setting a. Direct current 89. Exposure linearity must be accurate to within: b. Pulsating direct current a. 4 c. Pulsating direct current with 120 pulses per sec- b. 5% ond c. 2% of SID d. Pulsating direct current with 120 pulses per sec- d. 10% ond and 100% ripple 90. Exposure reproducibility must be accurate to within: 81. Three-phase, 6-pulse full-wave rectification produces: a. 4 a. Direct current with 13% ripple b. 5% b. Direct current with 4% ripple c. 2% of SID c. Direct current with 100% ripple d. 10% d. Alternating current with 13% ripple 91. Fluoroscopy exposure rate may not exceed: 82. Three-phase, 12-pulse full-wave rectification produces: a. 10 mGya per minute a. Direct current with 13% ripple b. 100 mGya per minute b. Direct current with 4% ripple c. 5 mGya per minute c. Direct current with 100% ripple d. 1 mGya minute d. Alternating current with 13% ripple 92. The feature that automatically adjusts kVp and mA 83. The increase in average photon energy when using during fluoroscopy is called: three-phase, 6-pulse equipment compared with single- a. AEC phase equipment is: b. ABC a. 1.35% c. DQE b. 41% d. SNR c. 1.41% 93. The test that measures the accuracy of adjacent mA d. 35% stations is: 84. The increase in average photon energy when using three- a. Exposure reproducibility phase, 12-pulse equipment compared with single-phase b. Spinning top test equipment is: c. Pinhole camera a. 1.35% d. Exposure linearity b. 41% 94. The test that measures the accuracy of successive c. 1.41% exposures is: d. 35% a. Exposure reproducibility 85. Programs that deal with the safe and reliable opera- b. Spinning top test tion of equipment and programs that address all c. Pinhole camera aspects of the delivery of radiology services are called, d. Exposure linearity respectively: 95. The accuracy of the timer must be within: a. Quality assurance and quality control a. 10% of the time chosen for exposures over 10 ms b. Total quality improvement b. 5% of the time chosen for exposures over 10 ms c. Quality control and quality assurance c. 5% of the time chosen for exposures under 10 ms d. Total quality management d. 10% of the time chosen for exposures under 86. An image intensifier’s conversion factor is expressed as 10 ms the ratio of: 96. Resolution of the television system may be measured a. The flux gain to the minification gain using the following tool(s): b. The luminance of the output phosphor to the a. Wire mesh test exposure rate at the input phosphor b. Line pairs/millimeter resolution tool along with a c. The exposure rate at the output phosphor to the kVp meter exposure rate at the input phosphor c. Resolution test pattern d. The size of the input phosphor to the size of the d. Resolution test pattern, wire mesh test, or line output phosphor pairs/millimeter resolution tool 87. The collimator must be accurate to a level of: 97. AECs may be tested using: a. ±4% of SID a. Phantoms b. ±5% of SID b. Images of real patients c. ±2% of SID c. Analog meters d. ±10% of SID d. Fluoroscopic screens Chapter 4 Image Production 85

98. The number of mAs used for analog fluoroscopy is: 7. The active portion(s) of a CR IP is (are): a. 300 to 500 a. ABC b. 3 to 5 b. PSP c. 10 to 12 c. DQE d. 100 to 300 d. SNR 99. Marks on the focal track of the anode resulting from 8. mAs directly control: bombardment of electrons are called: a. The energy of the x-ray emission spectrum a. Melts b. The quality and quantity of x-rays produced at the b. Bullet marks cathode c. Pitting c. The quality and quantity of x-rays produced at the d. Cracks anode 100. Effective quality control and quality assurance pro- d. The quantity of x-rays produced at the anode grams are required for accreditation by: 9. Visible differences in adjacent structures on a radio- a. The Joint Commission graphic image describe: b. Joint Review Committee on Education in Radio- a. Receptor exposure logic Technology b. Spatial resolution c. American Healthcare Radiology Administrators c. Signal loss d. American Registry of Radiologic Technologists d. Contrast resolution 10. The primary controlling factor(s) of contrast is Review Questions for Digital Image Acquisition (are): 1. Receptor exposure may be defined as: a. mAs, which control the energy of the x-rays pro- a. Amount of remnant radiation striking the image duced receptor b. kVp, which primarily controls the quantity of b. Dose area product x-rays produced at the target c. DQE c. Focal-spot size, which controls the quantity and d. Differences in dark areas on a radiographic image quality of x-rays produced 2. The radiographic image is formed by: d. kVp and bit depth a. Exit rays striking the image receptor 11. The relationship between kVp and receptor exposure b. Laser light may be described as: c. Cosmic rays a. Directly proportional d. Electrons and heat b. Direct, although not proportional 3. The primary controlling factors of receptor exposure c. Governed by the 15-50 rule are: d. Controlled by x-ray tube current a. kVp and mAs 12. The 15% rule states that: b. mAs and SID a. Receptor exposure may be halved by decreasing c. SID and OID kVp by 15% d. SID, OID, FSS b. kVp should be 15% of the mAs selected 4. Which of the following describes the relationship c. Receptor exposure may be halved by increasing between mAs and receptor exposure? kVp by 15% a. Receptor exposure is directly proportional to mAs d. At least a 15% change in mAs is required to make b. Receptor exposure is inversely proportional to a change visible mAs 13. Choose all of the following statements that are accu- c. Receptor exposure is directly proportional to mAs2 rate pertaining to the role of kVp in radiographic d. mAs controls the number of electrons boiled off image production (choose 3): the anode and the number of x-rays produced a. As kVp is increased, penetrating ability of the 5. The number of electrons boiled off the cathode and x-rays increases consequently the number of x-rays produced are con- b. As kVp is increased, more x-rays exit the patient to trolled by: strike the image receptor a. kVp c. As kVp is decreased, wavelength decreases b. SID d. As kVp increases, receptor exposure increases c. mAs e. As kVp decreases, receptor exposure remains con- d. OID stant because mAs controls receptor exposure 6. Receptor exposure was formerly called: 14. Given an original technique of 30 mAs and 80 kVp, a. Contrast which of the following would produce an image with b. Detail double the receptor exposure? c. Density a. 60 mAs, 90 kVp d. Distortion b. 30 mAs, 92 kVp 86 PART 1 Review and Study Guide

c. 15 mAs, 80 kVp 23. As beam restriction increases (becomes tighter): d. 30 mAs, 70 kVp a. Receptor exposure increases 15. Which of the following governs the relationship b. Receptor exposure increases as a result of focusing between SID and receptor exposure? of x-rays a. Reciprocity law c. Receptor exposure decreases b. 15% rule d. Receptor exposure is not affected c. Inverse square law 24. Which of the following affects receptor exposure? d. Ohm’s law a. Atomic mass of the x-ray tube anode 16. If SID is doubled, what may be said about receptor b. X-ray tube angle exposure? c. Atomic number of the cathode filament a. Receptor exposure doubles 25. The variation of x-ray intensity along the longitudinal b. Receptor exposure is reduced by one half axis of the x-ray beam describes: c. Receptor exposure is reduced by new mAs2 a. Beam collimation d. Receptor exposure is reduced to one fourth b. Positive beam limitation 17. If SID is reduced by one half, what must be done to c. Anode heel effect mAs to maintain a constant receptor exposure? d. X-ray emission spectrum a. Reduce mAs to one fourth its original value 26. The thicker part of anatomy should be placed under b. Reduce mAs to one half its original value which aspect of the x-ray tube? c. Increase mAs by four times its original value a. Central ray d. Increase mAs by two times its original value b. Cathode 18. Choose all factors below that result in poor spatial c. Anode resolution (choose 4): d. Collimator a. Long SID 27. The function of contrast is to: b. Long OID a. Make the image appear sharper c. Large focal spot b. Compensate for uneven anatomic structures d. Small focal spot c. Brighten the image e. Patient motion d. Make detail visible f. Magnification 28. A radiographic image with few gray tones, primar- 19. In digital fluoroscopy, what equipment should be ily exhibiting black and white, would be described as used to view the image? having what type of contrast? a. Conventional view box 1. Long scale b. High-resolution monitor capable of displaying 2. Short scale millions of pixels 3. Low c. High-definition television 4. High d. Plasma television required a. 2 and 4 20. A primary advantage to digital fluoroscopy is: b. 1 and 3 a. Postprocessing manipulation of the image c. 1 and 4 b. Radiation dose to the patient is substantially lower d. 2 c. No radiologist is needed 29. Lower spatial resolution may be caused by which of d. Lower cost the following factors? 21. Which of the following describes the relationship a. Short OID between receptor exposure and the use of grids? b. Long SID a. Grids always reduce receptor exposure c. Small focal spot b. Grids reduce receptor exposure unless mAs are d. Wide pixel pitch increased to compensate 30. Choose all that describe the outcome of using high c. Grids reduce receptor exposure by only absorbing kVp (choose 3): scatter radiation a. High contrast d. Receptor exposure increases as grid ratio increases b. Few gray tones 22. The use of filtration: c. Long-scale contrast a. Greatly reduces receptor exposure because of the d. Short-scale contrast absorption of short-wavelength x-rays e. Low contrast b. Greatly reduces radiographic receptor exposure f. Many gray tones because of the absorption of high-energy x-rays 31. Choose all that describe the outcome of using low c. Increases radiographic receptor exposure by removing kVp (choose 3): long-wavelength x-rays a. High contrast d. Has little effect on receptor exposure because x-rays b. Few gray tones removed from beam are not image-producing rays c. Long-scale contrast Chapter 4 Image Production 87

d. Short-scale contrast 40. Choose all that will result in higher spatial resolution e. Low contrast (choose 3): f. M any gray tones a. Long SID 32. More uniform penetration of anatomic structures b. Long OID occurs when what level of kVp is used? c. Short SID a. Low d. Short OID b. High e. Large focal spot c. kVp does not affect penetration f. S mall focal spot d. Lev el at which photoelectric interaction predomi- 41. Optimal spatial resolution may be created using nates which of the following factors? 33. D ifferential absorption of the x-ray beam is a function a. Large focal spot of: b. N arrow pixel pitch a. Compton interaction c. Long OID b. A tomic mass of anatomic structures d. Short SID c. mAs 42. I mproper use of grids may result in an image artifact d. Photoelectric interaction known as: 34. What effect does beam restriction have on a. SNR contrast? b. Moiré pattern a. D ecreases contrast by focusing the x-ray beam c. Elongation b. Decreases contrast because of higher kVp level d. Foreshortening used 43. D istortion may be described as: c. I ncreases contrast by focusing the x-ray beam a. M isrepresentation of an anatomic structure on the d. Increases contrast because of reduction in the image number of Compton interactions that occur b. Foreshortening 35. The adjustment in technical factors equiredr when c. Elongation using beam restriction is: d. Magnification a. Increase kVp 44. E longation and foreshortening are examples of: b. D ecrease kVp to reduce the number of Compton a. Size distortion interactions taking place b. Shape distortion c. D ecrease mAs to reduce the number of Compton c. Motion interactions taking place d. D istortion caused by short SID and long OID d. Increase mAs to compensate for the number of 45. M agnification is caused by: rays removed from the primary beam 1. Short SID 36. What effect does the use of radiographic grids have on 2. Long SID contrast? 3. Short OID a. Decreases contrast 4. Long OID b. Increases contrast a. 2, 3 c. N o effect on contrast b. 1, 4 d. I ncreases contrast by absorbing scatter radiation c. 1, 3 37. As the amount of beam filtration is increased: d. 1 only a. Contrast increases 46. D istortion that occurs when the x-ray beam is angled b. Ther e is no effect on contrast against the long axis of a part is: c. Contrast decreases a. Elongation d. Contrast increases because the beam is harder b. Magnification 38. The portion of contrast that is caused by variations c. Minification in the anatomy or that is secondary to pathologic d. Foreshortening changes is called: 47. D istortion that occurs when the x-ray beam is angled a. Radiographic contrast along the long axis of a part is: b. Anatomic contrast a. Elongation c. Pathologic contrast b. Magnification d. Subject contrast c. Minification 39. S patial resolution is: d. Misrepresentation a. Photographic representation of the part being 48. The actual patient dose as measured by a meter radiographed embedded in the collimator is: b. Contr olled by kVp a. RAD—radiation absorbed dose c. Contr olled by mAs b. DAP—dose area product d. G eometric representation of the part being radio- c. REM—radiation equivalent man graphed d. Doubling dose 88 PART 1 Review and Study Guide

49. Quality assurance and maintenance of CR cassettes 59. Digital systems operate at what speed class? include cleaning and inspecting the plates at least: a. 200 a. Daily b. 400 b. Every 48 hours c. 100 c. Every 3 months d. The speed class chosen by the radiographer d. Weekly 60. An artificial increase in display contrast at an edge of 50. Quality assurance and maintenance of CR cassettes the image is: include erasing plates at least: a. Smoothing a. Daily b. Edge enhancement b. Every 48 hours c. Contrast resolution c. Every 3 months d. Spatial resolution d. Weekly 61. As speed class increases: 51. Quality assurance of digital imaging requires the uni- a. The likelihood of noise increases formity of processing codes to ensure: b. The likelihood of noise decreases a. Image appearance consistency c. Patient exposure increases b. Faster throughput d. Sharpness increases c. Less heat loading on the anode 62. As speed class decreases: d. Smoother integration into PACS a. The likelihood of noise increases 52. A software function that evens the brightness dis- b. Noise is unaffected played in the image is called: c. Patient exposure increases a. Smoothing d. Sharpness decreases b. Equalization 63. Smoothing software may result in: c. Postprocessing a. Enhanced fine detail d. Subtraction b. Less distortion 53. Beam-part-receptor alignment latitude describes: c. Loss of fine detail a. The latitude of collimation that still allows the d. Increased distortion software to detect collimated edges 64. Excessive processing of the digital image may: b. The alignment that maintains ALARA require- a. Degrade visibility of anatomy ments b. Provide additional anatomic information c. Exposure latitude c. Enhance visibility of desired anatomy d. Acceptable distortion of the image d. Increase patient dose 54. To reduce patient dose, exposure technique in digital 65. A high SNR provides an image with: imaging should be adjusted by: a. Poor spatial resolution a. Lowering kVp b. Higher spatial resolution b. Increasing mAs c. Poor contrast c. Shortening SID d. Higher distortion d. Increasing kVp 66. Quantum noise limits ability to see: 55. Digital image receptors are more sensitive to: a. Detail a. Scatter and background radiation b. Contrast b. Fluorescent lights c. Fatty tissue c. Free electrons d. Additive pathologies d. Free radicals 67. If the exposure field is not accurately recognized, the 56. In digital radiography inappropriate collimation causes: histogram will contain data: a. A fogged image a. Outside the exposure field, narrowing the histo- b. Pixel unresponsiveness gram c. DICOM incompatibility b. Inside the exposure field, widening the histogram d. Histogram analysis error c. Outside the exposure field, widening the histogram 57. The appearance of digital images on technologists’ d. Inside the exposure field, narrowing the histogram monitors is: 68. Grid ratio is defined as: a. The same as on radiologists’ monitors a. The ratio of the lead strips to the space between b. Substantially better than on radiologists’ monitors them c. Not as good as on radiologists’ monitors b. The thickness of the lead strips divided by the 58. Digital imaging is driven by: thickness of the aluminum interspacers a. kVp c. The ratio of the height of the lead strips over the b. mAs distance between the lead strips c. IR speed class d. The ratio of the distance between the lead strips d. Exposure over the height of the lead strips Chapter 4 Image Production 89

69. Grid frequency is defined as: 76. Use of the air gap technique: a. The same as grid ratio a. Works because x-rays are absorbed in the air b. The amount of lead in the grid (expressed in terms between the patient and the film of focusing distance) b. Should occur when possible c. How often a grid is used c. May cause some magnification because of decreased d. The amount of lead in the grid (expressed as the OID number of lead strips per inch) d. Works because scatter radiation travels in divergent 70. Choose all that are true concerning grids (choose 3): paths and misses the IR as a result of increased OID a. Contrast improvement factor is the measure of the 77. Use of technique charts: ability of a grid to enhance contrast a. Is unnecessary for any exam because of AECs b. Grid selectivity is the ratio of primary radiation b. Does not require that the part thickness be mea- transmitted through the grid to secondary radia- sured with calipers tion transmitted through the grid c. Is usually based on fixed mAs and variable kVp c. Grids are used when part thickness is less than 10 d. Is helpful when manual techniques are used cm 78. When AEC is used, increasing the kVp: d. GCF is the amount of increase in kVp necessary a. increases the exposure time when converting from nongrid to grid technique b. increases the image contrast e. The primary purpose of grids is radiation protec- c. decreases the exposure time tion d. has no effect on image quality f. The main function of grids is to prevent Compton 79. The CR reader unit scans the IP with a(n): scatter from reaching the IR a. Infrared light g. Grids prevent the production of scatter b. Laser 71. A grid with lead strips and aluminum interspacers c. Sonar that are angled to coincide with the divergence of the d. Visible white light x-ray beam is called a: 80. Which of the following maintains image brightness a. Parallel grid over a wide range of exposures? b. Focused grid a. AEC c. Crosshatch grid b. Bit depth d. Rhombic grid c. Automatic rescaling 72. The range of SIDs that may be used with a focused d. Detector size grid is called: 81. The available gray scale of an imaging system is deter- a. Grid ratio mined by: b. Objective plane a. Pixel pitch c. Anticutoff distances b. Bit depth d. Grid radius c. Exposure latitude 73. The best scatter cleanup is achieved with the use of: d. Image latitude a. Air gap technique 82. The smallest exposure change able to be captured by a b. Focused grids detector is called: c. Crosshatch grids a. Spatial resolution d. Parallel grids b. Exposure latitude 74. Grid cutoff may be described as: c. Pixel a. Decreased density in the middle of the radiograph d. Contrast resolution caused by the use of a parallel grid inserted upside 83. An indicator of the dose level needed to acquire an down optimal image is: b. Decreased density on a radiograph as a result of a. Detective quantum efficiency absorption of image-forming rays b. Dose area product c. Increased density in the center of a radiograph caused c. Field of view by the use of a focused grid inserted upside down d. Dynamic range d. Decreased density on the edges of a radiograph 84. The useful image acquisition area of an image recep- only tor is: 75. When a nongrid technique using 10 mAs and 75 kVp a. Detector element is changed to a 12:1 grid using 75 kVp, what new b. Detector size mAs must be used to create the same image? c. TFT size a. 50 mAs d. Dynamic range b. 2 mAs 85. The smallest resolvable area in a digital imaging device is: c. 40 mAs a. Detector size d. 120 mAs b. Detector element 90 PART 1 Review and Study Guide

c. Matrix size 93. What converts light into a charge? d. Focal-spot size a. Diode 86. What allows more anatomic structures to be captured b. Cathode during an exposure? c. AC to DC converter a. Contrast resolution d. Photodiode b. Spatial resolution 94. The smallest area represented in a digital image is the: c. Dynamic range a. Image matrix d. MTF b. Pixel 87. The range of receptor exposures that provides a qual- c. Voxel ity image is called: d. Bit a. Detector latitude 95. The number of pixels/mm in an image is called: b. Exposure latitude a. Pixel density c. Histogram b. Bit depth d. Dynamic range c. Pixel pitch 88. Which of the following is a graphical representation d. Matrix depth of pixel values? 96. The space from the center of a pixel to the center of a. Dynamic range the adjacent pixel is called: b. Luminance a. Pixel density c. Look-up table b. Bit depth d. Histogram c. Pixel pitch 89. Undesirable fluctuations in brightness are called: d. Matrix depth a. MTF 97. Mathematical codes used to generate the digital image b. Image noise are called: c. Quantization a. Binary codes d. Scintillation b. Algorithms 90. The number of pixels making up the digital image is c. Binary digits the: d. Bytes a. Pixel depth 98. The process of assigning a value to each pixel to repre- b. Matrix size sent a gray tone is called: c. Pixel pitch a. Quantization d. Field of view b. Scintillating 91. The expression of image quality provided by a detec- c. Nyquist frequency tor is called: d. Sampling a. MTF 99. A material that absorbs x-ray energy and emits part of b. Matrix size that energy as visible light is called: c. SNR a. Diode d. Nyquist frequency b. Scintillator 92. Which of the following terms describes the highest c. TFT spatial frequency that can be recorded by a digital d. Cathode detector? 100. Bit depth is equal to: a. Spatial resolution a. 2n (n equals the number of bits) b. Contrast resolution b. 4096 shades of gray c. MTF c. Pixel pitch d. Nyquist frequency d. Bits times bytes 5 Procedures

BASIC PROCEDURES AND POSITIONING TERMINOLOGY Anterior or ventral forward or front Dorsal decubitus patient lying on back; central ray parallel to Caudal inferior, away from the head the floor (horizontal); lateral projection Central mid-area Ventral decubitus patient lying on abdomen; central ray paral- Cranial cephalic, superior, toward the head lel to the floor (horizontal); lateral projection Distal farthest from the origin or point of reference Tangential central ray skims between body parts or skims Lateral away from the median plane of the body or the middle body surface; shows profile of body part, free of superim- of a part position Medial toward the median plane of the body or the middle of Axial longitudinal angulation of the central ray with the a part long axis of the body part; projection that refers to images Posterior dorsal; back of a part (not used to describe the obtained with central ray angled 10 degrees or more along foot) long axis of part Proximal nearer origin or point of reference Orbitomeatal line (OML) line from outer canthus of the Dorsal recumbent supine, lying on back eye to the auricular point; also called the radiographic Ventral recumbent prone, lying face down baseline Right lateral recumbent lying on right side Infraorbitomeatal line (IOML) line from just below the eye to Left lateral recumbent lying on left side the auricular point; also called Reid’s baseline Projection path of the central ray Glabellomeatal line line from the glabella to the auricular Position placement of the body or part point View image as seen by the image receptor (opposite of Acanthiomeatal line (AML) line from the acanthion to the projection) auricular point Oblique body rotated from supine, prone, or lateral Median sagittal plane (MSP) plane that passes vertically Right anterior oblique (RAO) angle that places right through the midline of the body from front to back; also anterior portion of the body closest to the image called midsagittal plane receptor Sagittal plane any plane parallel to the MSP Left anterior oblique (LAO) angle that places left anterior Midcoronal plane plane that passes vertically through midaxil- portion of the body closest to the image receptor lary region of the body and coronal suture of the cranium at Left posterior oblique (LPO) angle that places left posterior right angles to the MSP part of the body closest to the image receptor Coronal plane any plane passing vertically through the body Right posterior oblique (RPO) angle that places right from side to side posterior portion of the body closest to the image Transverse plane passes crosswise through the body at right receptor angles to its longitudinal axis and the MSP and coronal Decubitus position patient lying down; central ray parallel to planes; also called axial plane the floor (horizontal) Left or right lateral decubitus patient lying on left or right side; central ray parallel to the floor (horizontal); anteroposterior (AP) or posteroanterior (PA) projection

91 92 PART 1 Review and Study Guide

Related Medical Terminology: Prefixes, Roots, and Suffixes Prefixes scler- hard phren diaphragm sub- below pneum air a-, an- without super- above pyel pelvis (renal) ab- away from trans- across viscer organ ante- front vent- front anti- against Suffixes bi- two Roots co- together -algia pain contra- against angio vessel -centesis puncture decub- side arth joint -ectasis expansion dors- back cardi heart -ectomy excision dys- difficult cephal brain -emia blood ect- outside cerebro head -genic origin en- in cerv neck -iasis condition endo- within chole bile -itis inflammation epi- on chondr cartilage -megaly enlargement ex- out cost rib -myel spinal cord hemi- half crani skull -oid like hydro- water cysto bladder -oma tumor hyper- above or greater derm skin -osis condition hypo- below or lesser encephal brain -pathy disease infero- below enter intestine -plasty surgical correction mega- large gastr stomach -pulm lung peri- around hem blood -pyel pelvis (renal) poly- many hepat liver -rhaphy suture post- after leuk white -scopy inspection pre- before lith stone -tomy incision pseudo- false nephr kidney retro- backward osteo bone

KEY REVIEW POINTS B. Alignment: The long axis of the body part should corre- Basic Procedures and Positioning Terminology spond to the long axis of the image receptor except when the image receptor must be rotated to fit the entire part • Be able to define and understand the use of each of the on the image receptor terms presented. C. Precise visualization • Be able to contrast the various recumbent, oblique, and 1. Positioning must be absolutely accurate decubitus positions. • Locate and understand the use of the various body 2. No rotation of image present lines and planes. D. Patient identification 1. Identification marker on image receptor should not obstruct view of relevant anatomy 2. Patient information should include patient’s name Basic Principles of Positioning and and date of exam Procedures* E. Anatomic markers 1. Right or left markers must always appear on the image; A. Body part placement use a radiopaque marker placed on the image receptor 1. Body part should be placed on the image receptor 2. Radiopaque markers must be placed just inside the in a position that allows for imaging of all anatomic collimation field and should not obstruct relevant features required for the procedure anatomy 2. Allows for tight collimation F. Other markers 1. Time: Time indicators should always be used when images are taken at specifically timed intervals * Positioning routines vary from text to text and from department to department. The following is a general review of common routines. Ques- 2. Direction: If the image was taken with the patient in tions on the certification exam could include any of these routines or com- an erect position, the lead marker indicating erect or binations and variations of specific positions. upright must appear on the image CHAPTER 5 Procedures 93

3. Inspiration/expiration: Must be used for comparison c. 8-degree angle with glabellomeatal line studies of the chest d. Also called the radiographic baseline 4. Internal/external: Must be used when both forms of 2. Infraorbitomeatal line (also called Reid’s baseline) rotation constitute part of an exam a. Line from just below the eye to the auricular 5. Numeric markers: Must be used when taking a series point of images in sequence (e.g., during trauma or surgical b. 7-degree angle with OML cases when follow-up is required in a short time) 3. Glabellomeatal line G. Routines a. Line from the glabella to the auricular point 1. Minimum of two projections per exam except for b. 8-degree angle with OML certain cases in which a single survey image suffices 4. Acanthiomeatal line (AML) (e.g., KUB) a. Line from the acanthion to the auricular point 2. A minimum of two projections, 90 degrees from one another, must always be taken KEY REVIEW POINTS a. Superimposition of structures may prevent visualization of some pathologic conditions Topography b. Lesions or foreign bodies require precise localization c. Fractures must be seen from two points precisely Positioning in the clinical setting and answering test questions 90 degrees from each other on the certification exam are predicated on your knowledge of d. Minimum of three projections (AP or PA, lateral, and topography. Be certain you can identify these baselines. oblique) required for proper visualization of joints

KEY REVIEW POINTS Motion Control Basic Principles of Positioning and Procedures A. Involuntary motion (controlled with short exposure These are basic points you learned early in positioning time and high-speed image receptor) class. They are simple concepts that may be used as straightforward questions or to form the basis of more 1. Cardiac motion complex questions. Master them. 2. Peristalsis 3. Muscular spasm 4. Chills 5. Pain Topography B. Voluntary motion 1. Belligerence A. Cervical region 2. Excitement 1. C1: Mastoid tip 3. Fear 2. C2, C3: Gonion 4. Nervousness 3. C5: Thyroid cartilage 5. Painful discomfort 4. C7: Vertebra prominens 6. Age (children, elderly) B. Thoracic region 7. Controlled by use of the following: 1. T1: 2 inches above sternal notch a. Clear communications 2. T2, T3: Level of manubrial notch and superior b. Sandbags margin of scapula c. Sponges 3. T4, T5: Level of sternal angle d. Tape 4. T7: Level of inferior angle of scapula e. Short exposure time 5. T10: Level of xiphoid tip f. Patient comfort C. Lumbar region g. Compression bands 1. L3: Costal margin h. Pediatric immobilizer (e.g., Pigg-O-Stat, for 2. L3, L4: Level of umbilicus infants) 3. L4: Level of superiormost aspect of iliac crest i. Sheets for mummification techniques (for D. Sacrum and pelvic region children) 1. S1: Level of anterior superior iliac spine (ASIS) j. Instructions—clearly explain the exam to the 2. Coccyx: Level of pubic symphysis and greater trochanters patient E. Lines k. Obtain signature on consent form if required 1. Orbitomeatal line (OML) l. Ask patient if he or she has any questions, ensur- a. Line from outer canthus of the eye to the auricular ing informed consent point m. Describe exam in terminology the patient under- b. 7-degree angle with infraorbitomeatal line (IOML) stands 94 PART 1 Review and Study Guide

n. Describe exactly what will be done to the patient, Body Habitus including the approximate number of images to be taken and the duration of the exam A. Hypersthenic o. Explain the reasons for removal of clothing and 1. Massive build the extent of gowning 2. Represents 5% of population p. Explain the reason for removal of all radiopaque 3. Thorax is broad and deep objects in the area of interest 4. Ribs are almost horizontal q. Describe the required breathing pattern and the 5. Thoracic cavity is shallow reasons for its use 6. Lungs are short; narrow above and broad at the base 7. Heart is short and wide KEY REVIEW POINTS 8. Diaphragm is high 9. Upper abdominal cavity is broad; lower part is small Motion Control 10. Stomach and gallbladder are high and horizontal 11. Colon is high Be sure you can compare and contrast involuntary with B. Sthenic voluntary motion. Understand all the factors that control each. 1. Slight modification of hypersthenic 2. Most common body habitus 3. Present in 50% of population C. Hyposthenic Exposure Modification 1. Between asthenic and sthenic 2. Present in 35% of population A. Use of optimal radiographic technique ensures proper D. Asthenic visualization of body parts 1. Slender build B. Exposure technique may require modification because 2. Present in 10% of population of some factors 3. Thorax is narrow and shallow 1. Pathologic conditions 4. Ribs slope sharply downward 2. Age 5. Thoracic cavity is long 3. Conditions under which the images are being taken 6. Lungs are long, broader above than at the base (e.g., mobile radiography, cross-table projections) 7. Heart is long and narrow 4. Body habitus 8. Diaphragm is low, and abdominal cavity is short 9. Stomach and gallbladder are low, vertical, and near KEY REVIEW POINTS the midline 10. Colon is low, at median position Exposure Modification KEY REVIEW POINTS By using this knowledge and the information in Chapter 4, you should be able to identify the various factors that affect Body Habitus exposure technique. Have a working knowledge of the changes needed and how to perform them. Every patient is unique, but each fits into a certain category. Be able to identify each body habitus and the anatomy of each.

Gonadal Shielding Pediatric Radiography: General Principles A. Used when gonads are within the primary beam or within 5 cm of the primary beam A. Appropriately introduce radiographer to child and parent B. Used if the shielding does not interfere with the purpose B. Radiographer should show a positive attitude toward the of the exam child C. Used on patients of reproductive age and younger C. Maintain clear communication with child and parent D. Determine extent of parental involvement E. Report suspected child abuse (nonaccidental trauma) to KEY REVIEW POINTS the appropriate radiologist, attending physician, radiology supervisor, or nurse Gonadal Shielding F. Determine type of immobilization to be used for the exam Understand the process of gonadal shielding and its role in radiation protection. Review the material in Chapter 3. 1. Immobilization board 2. Pediatric immobilizer (e.g., Pigg-O-Stat) 3. Sandbags CHAPTER 5 Procedures 95

4. Tape K. Allow patient as much control over movement as possible 5. Compression bands L. Whether patient is conscious or unconscious, explain your 6. Sheets and towels movements clearly to encourage possible cooperation G. Practice as low as reasonably achievable (ALARA) principle M. Be prepared to perform several exams at once 1. Gonadal shielding of children 1. Example: All AP projections should be taken in an 2. Tight collimation uninterrupted sequence, then all lateral projections, 3. Pieces of lead used as contact shields and so on 4. Low mAs techniques 2. Reduces the number of times the patient or x-ray 5. No repeat images tube must be moved H. Determine whether patient preparation was adequately 3. Allows overall procedure to be completed more carried out quickly I. Interview the parent and write down the appropriate N. Provide lead aprons for anyone who may need to be in history the room caring for a critically injured patient J. Briefly discuss case with radiologist to determine spe- O. Move patient’s extremities carefully to avoid displacing cifically which projections are needed and the extent of fractures further or causing internal hemorrhage gonadal shielding that should be used if this is in doubt P. Maintain a cooperative spirit 1. Cooperate with other health care professionals, such KEY REVIEW POINTS as phlebotomists, respiratory therapists, physicians, and nurses, who may need to be caring for the patient Pediatric Radiography: General Principles simultaneously during the radiographic exam in cases of severe trauma Pediatric radiography requires specific skills, attention to detail, and attention to radiation protection. Be aware of all of 2. The radiographer is a vital part of a trauma team the points in this section. and needs to work in harmony with the other health care professionals present for the proper care of the patient Q. Inability of the patient to move and difficulty obtaining Trauma: General Principles routine projections must never be used as an excuse to submit poor-quality images A. Do no additional harm to the patient 1. Patients with severe trauma need fully diagnostic B. Work quickly and confidently, observing standard images to receive optimal care precautions 2. The radiographer must be proficient in radiographic C. Be prepared to modify conventional positions in response exposure and positioning so that high-quality images to patient’s condition may be obtained under difficult conditions D. If patient is immobilized, transfer the patient to the x-ray table with as much assistance as possible. KEY REVIEW POINTS E. Skull and cervical spine injuries Trauma: General Principles 1. Cross-table lateral cervical spine image must be obtained before the patient is moved in any way Trauma radiography requires fast, accurate work on the part 2. Image must be approved by a physician before patient of the radiographer. Be sure you understand each concept is moved or a cervical collar or sandbags are removed presented in this section. F. Each body part requires at least two images taken at 90-degree angles to one another G. Projections should approach routine positioning (as patient’s condition permits), with the image receptor Review of Anatomy Relevant to placed as close to the body part as possible Radiography H. Central ray entrance and exit points should be as close to routine as possible Planes of the Body I. Long bone radiography 1. Always include joint nearest the trauma A. Median sagittal plane (MSP); also called midsagittal plane 2. Joint farthest from the trauma should also be included 1. Passes vertically through the midline of the body if possible; otherwise, separate images should be taken from front to back of that joint 2. Divides body into equal right and left portions J. Splints or bandages 3. Any plane parallel to MSP is called a sagittal plane 1. Should not be removed unless permission has been B. Midcoronal plane obtained from the physician 1. Passes vertically through the midaxillary region of the 2. Modification of exposure technique may be necessary body and the coronal suture of the cranium at right to compensate for splints and bandages angles to the MSP 96 PART 1 Review and Study Guide

2. Divides body into anterior and posterior portions C. Epiphysis: Located at both ends of the diaphysis 3. Any plane passing vertically through the body from D. Growth in bone length is provided by the metaphyseal side to side is called a coronal plane plate, located between the epiphyseal cartilage and the C. Transverse plane (axial plane) diaphysis 1. Passes crosswise through the body at right angles to E. An osseous matrix is formed in the cartilage its longitudinal axis and the MSP and coronal planes F. Bone appears at the site where cartilage existed 2. Divides body into superior and inferior portions G. Ossification is completed as the proximal epiphysis joins with the diaphysis between 20 and 25 years of age Clinical Divisions of the Abdomen Marrow A. Divided into four quadrants by a transverse plane and A. Fills spaces of spongy bone MSP intersecting at the umbilicus B. Contains blood vessels and blood cells in various stages B. Quadrants of development 1. Right upper quadrant C. Red bone marrow 2. Right lower quadrant 1. Site of formation of red blood cells and some white 3. Left upper quadrant blood cells 4. Left lower quadrant 2. Found in spongy bone of adults a. Sternum Anatomic Divisions of the Abdomen b. Ribs c. Vertebrae A. Abdomen is divided into nine regions using four planes d. Proximal epiphysis of long bones 1. Two transverse planes D. Yellow bone marrow 2. Two sagittal planes E. Fatty marrow: Replaces red bone marrow in adults except B. Planes are called Addison’s planes in areas previously mentioned C. Transverse planes are drawn 1. At the levels of the tip of the ninth costal cartilage Types of Bones 2. At the superior margin of the iliac crest A. Long bones (e.g., femur, humerus) D. Two sagittal planes are drawn B. Short bones (e.g., wrist, ankle bones) 1. Each midway between ASIS of the pelvis and MSP of C. Flat bones (e.g., ribs, scapulae) the body D. Irregular bones (e.g., vertebrae, sesamoids [patella]) E. Nine regions of the body 1. Superior Descriptive Terminology for Bones a. Right hypochondrium A. Projections b. Epigastrium 1. Process: Prominence c. Left hypochondrium 2. Spine: Sharp prominence 2. Middle 3. Tubercle: Rounded projection a. Right lumbar 4. Tuberosity: Larger rounded projection b. Umbilical 5. Trochanter: Very large bony prominence c. Left lumbar 6. Crest: Ridge 3. Inferior 7. Condyle: Round process of an articulating bone a. Right iliac 8. Head: Enlargement at end of bone b. Hypogastrium B. Depressions c. Left iliac 1. Fossa: Pit Skeletal System 2. Groove: Furrow 3. Sulcus: Synonymous with groove Functions 4. Sinus: Cavity within a bone A. Provides rigid support system 5. Foramen: Opening B. Protects delicate structures 6. Meatus: Tubelike C. Bones supply calcium to the blood and are involved in formation of blood cells Division of the Skeleton D. Bones provide attachment of muscles and form levers in A. Axial skeleton the joint spaces, allowing movement 1. Composed of 74 bones 2. Upright axis of the skeleton Ossification 3. Components A. Cartilage is covered with perichondrium that is con- a. Skull verted to periosteum b. Hyoid bone B. Diaphysis: Central shaft c. Vertebral column CHAPTER 5 Procedures 97

d. Sternum 2. Flexion: Decreases angle formed by the union of two e. Ribs bones B. Appendicular skeleton 3. Extension: Increases the angle formed by the union of 1. Composed of 126 bones two bones 2. Bones attached to the axial skeleton 4. Abduction: Occurs by moving part of the appendicu- a. Upper and lower extremities lar skeleton away from the median plane of the body b. Auditory ossicles—6 bones 5. Adduction: Occurs by moving part of the appendicular skeleton toward the median plane of the body Articulations 6. Circumduction A. Classification basis a. Occurs in ball-and-socket joints 1. Structure b. Circumscribes the conic space of one bone by the 2. Composition other bone 3. Mobility 7. Rotation: Turning on an axis without being displaced B. Fibrous joints (synarthroses) from that axis 1. Surfaces of bones almost in direct contact, with limited movement Skull Morphology 2. Generally immovable A. Mesocephalic skull 3. No joint cavity or capsule 1. Considered “typical” skull 4. Examples: Skull sutures 2. Petrous ridge forms 47-degree angle with MSP C. Cartilaginous joints (amphiarthroses) B. Brachycephalic skull 1. No joint cavity; contiguous bones united by cartilage 1. Petrous ridge forms 54-degree angle with MSP and ligaments 2. Short from front to back 2. Slightly movable 3. Broad from side to side 3. Examples: Intervertebral disks, pubic symphysis 4. Shallow from vertex to base D. Synovial joints (diarthroses) C. Dolichocephalic 1. Approximating bone surfaces covered with cartilage 1. Petrous ridge forms 40-degree angle with MSP 2. Freely movable 2. Long from front to back 3. Bones held together by a fibrous capsule lined with 3. Narrow from side to side synovial membrane and ligaments 4. Deep from vertex to base 4. Examples of movement a. Hinge: Permits motion in one plane only (e.g., elbow) Axial Skeleton b. Pivot: Permits rotary movement in which a ring Skull rotates around a central axis (e.g., proximal radio- A. Cranium (Figures 5-1 and 5-2) ulnar articulation) 1. Superior portion formed by frontal parietal and c. Saddle: Opposing surfaces are concavo-convex, occipital bones allowing flexion, extension, adduction, and abduc- 2. Lateral portions formed by temporal and sphenoid tion (e.g., carpometacarpal joint of thumb) bones d. Ball and socket: Capable of movement in an infi- 3. Cranial base formed by temporal, sphenoid, and eth- nite number of axes; rounded head of one bone moid bones moves in a cuplike cavity of the approximating 4. Fontanelles: Soft spots at birth in which ossification is base (e.g., hip) incomplete e. Gliding: Articulation of contiguous bones allows B. Frontal bone only gliding movements (e.g., wrist, ankle) 1. Forms the forehead f. Condyloid: Permits movement in two directions at 2. Contains the frontal sinuses right angles to one another; circumduction occurs, 3. Forms the roof of the orbits rotation does not (e.g., radiocarpal joints) 4. Union with the parietal bones forms the coronal E. Bursae suture 1. Sacs filled with synovial fluid; located where tendons C. Parietal bones or muscles slide over underlying parts 1. Union with occipital bone forms the lambdoid suture 2. Some bursae communicate with a joint cavity 2. Union with temporal bone forms the squamous suture 3. Prominent bursae found at the elbow, shoulder, hip, 3. Union with sphenoid bone forms the coronal suture and knee D. Temporal bones F. Movements 1. Contain the external auditory meatus and middle 1. Gliding and inner ear structures a. Simplest kind of motion in a joint 2. Squamous portion: Above the meatus; zygomatic pro- b. Motion of a joint that does not involve any angu- cess articulates with the zygoma to form the zygo- lar or rotary movements matic arch 98 PART 1 Review and Study Guide

Frontal bone

Glabella Coronal suture

Supraorbital Parietal bone notch

Sphenoid bone Lesser wing Nasal bone Greater wing Lacrimal bone

Temporal bone Zygomatic bone Frontal process Ethmoid bone Orbital surface Orbital plate Temporal process Perpendicular plate Middle nasal concha

Maxilla Inferior nasal concha Orbital surface Vomer

Zygomatic process Mandible Infraorbital foramen Ramus Body Alveolar process Mental foramen Anterior nasal spine Mental protuberance

• Figure 5-1 Skull (anterior view).

Coronal suture Parietal bone Pterion Sphenoid bone Temporal bone Greater wing Temporal fossa Squamous part Frontal bone Zygomatic process External acoustic meatus Supraorbital notch Mastoid process

Glabella

Ethmoid bone Lambdoid suture Orbital plate Lacrimal bone Occipital bone Nasal bone External occipital Maxilla protuberance Frontal process Anterior nasal spine Mandible Alveolar process Head (caput) of condylar process Zygomatic bone Notch Temporal process Coronoid process Ramus Zygomatic arch Body

• Figure 5-2 Skull (lateral view). CHAPTER 5 Procedures 99

3. Petrous portion c. Medial and lateral pterygoid processes located a. Contains organs used for hearing and equilibrium here b. Prominent elevation on the floor of the cranium F. Ethmoid bone 4. Mastoid portion 1. Contributes to formation of the base of the cranium, a. Protuberance behind the ear orbits, and roof of the nose b. Mastoid process 2. Perpendicular plate: Forms superior part of the nasal 5. Mandibular fossa: Articulates with the condyle on the septum mandible 3. Horizontal plate (cribriform plate) 6. Styloid process: Anterior to the mastoid process; sev- a. Located at right angles to perpendicular plate eral neck muscles attach here b. Olfactory nerves pass through 7. Jugular foramen: Located between the petrous portion c. Contains the crista galli; meninges of the brain and the occipital bones; opening from which CN attached to this process (cranial nerve) IX, CN X, and CN XI exit 4. Lateral masses E. Sphenoid bone a. Form the orbital plates 1. Bounded by the ethmoid and frontal bones anteriorly b. Contain superior and middle conchae (lateral and by the temporal and occipital bones posteriorly walls of the nose) 2. Greater wings: Lateral projections (Figure 5-3) c. Contain ethmoid sinuses a. Form outer wall and floor of the orbits G. Occipital bone b. Foramen rotundum: Round; located horizontally 1. Forms the posterior part of the cranium in anteromedial portion of the greater wing, adja- 2. Foramen magnum: Spinal cord enters to attach to cent to lateral wall of the sphenoid sinus; maxillary brainstem division of CN V exits 3. Condyles (two) c. Foramen ovale: Oval; located laterally and posteri- a. On both sides of the foramen magnum orly to foramen rotundum; mandibular division of b. Articulate with depressions on C1 vertebrae CN V exits 4. External occipital protuberance: Located on the poste- d. Foramen spinosum: Located near posterior angle of rior surface the greater wing; lateral and posterior to foramen ovale; transmits an artery to the meninges Facial Bones e. Foramen lacerum: Contains internal carotid artery A. Appear suspended from middle and anterior parts of the f. Superior orbital fissure: Transmits CN III and CN cranium IV and part of CN V B. Ethmoid and frontal bones also contribute to the frame- 3. Lesser wings work of the face a. Posterior part of the roof of the orbits C. Maxilla b. Optic foramen: CN II exits 1. All facial bones except the mandible touch the 4. Body maxilla a. Sella turcica: Holds the pituitary gland (hypophysis) 2. Alveolar process: Forms upper jaw containing the max- b. Contains the sphenoid sinuses illary teeth

Posterior and Orbital surface of anterior ethmoidal frontal bone foramina Orbital surface of lesser wing of Orbital plate of sphenoid bone ethmoid bone

Superior orbital Orbital process of fissure palatine bone Optic canal Lacrimal bone Orbital surface of greater wing of Orbital surface sphenoid bone of maxilla Orbital surface of Infraorbital groove zygomatic bone

Inferior orbital fissure • Figure 5-3 Right orbit. 100 PART 1 Review and Study Guide

3. Forms the floor of the orbits; infraorbital foramen is K. Hyoid inferior from the orbit 1. U-shaped bone 4. Forms the walls of the nasal cavities and the hard 2. Body palate (palatine process) 3. Greater horn 5. Maxillary sinus: Large air space 4. Lesser horn D. Mandible (Figure 5-4) 5. Suspended by ligaments from the styloid process 1. Body: Central horizontal portion a. Chin: Symphysis in midline Vertebral Column b. Alveolar process: Contains the mandibular teeth A. Part of the axial skeleton c. Mental foramen 1. Supports the head (1) Below the first bicuspid on the outer surface 2. Gives base to the ribs (2) Transmits nerves and blood vessels 3. Encloses the spinal cord 2. Ramus: Upward process on both sides of the posterior B. Vertebrae body of the mandible 1. Consist of 34 bones that make up the spinal column a. Condyle: Articulates with the mandibular fossa a. Cervical: 7 bones b. Coronoid process: Attachment site for the tempora- b. Thoracic: 12 bones lis muscle c. Lumbar: 5 bones c. Mandibular foramen: Located on the inner d. Sacral: 5 bones surface e. Coccygeal: 4 or 5 bones E. Zygomatic bone 2. In adults, the vertebrae of the sacral and coccygeal regions 1. Prominence of cheek: Attaches to zygomatic process of are united into two bones, the sacrum and the coccyx the temporal bone to form the zygomatic arch C. Curvatures: From a lateral view, there are four curves, 2. Other margin of the orbit alternately convex and concave ventrally F. Lacrimal: Medial part of the wall of the orbit 1. The two convex curves are the cervical and lumbar G. Nasal bones: Upper bridge of the nose 2. The two concave curves are the thoracic and sacral H. Inferior nasal concha D. Vertebral morphology 1. Horizontally placed along the lateral wall of the nasal 1. Each vertebra differs in size and shape but has similar fossa components 2. Inferior to the middle and superior conchae of the 2. Body: Central mass of bone ethmoid a. Weight bearing I. Palatine bones b. Forms anterior part of vertebrae 1. Horizontal plates form the posterior part of the hard 3. Pedicles of the arch: Two thick columns that extend palate backward from the body to meet the laminae of the 2. Perpendicular plates form the sphenoid palatine neural arch foramen 4. Processes: Seven (one spinous [except C1], two trans- J. Vomer verse, two superior articular, and two inferior articular) 1. Plowshare-shaped bone a. Spinous process extends backward from the point 2. Forms the lower part of the nasal septum of the union of the two laminae b. Transverse processes project laterally on both sides

Condylar process Head (caput) from the junction of the laminae and the pedicle Coronoid process c. Articular processes arise near the junction of the Pterygoid fossa pedicle and the laminae; superior processes project Neck upward, inferior processes project downward Notch (incisure) d. Surfaces of the processes are smooth e. Inferior articular processes of the vertebrae fit into the superior articular processes below f. Form true joints, but the contacts established serve to restrict movement E. Distinguishing features Ramus 1. Cervical region: Triangular shape a. All have foramina in the transverse processes (upper six transmit the vertebral artery) Mental protuberance Angle b. Spinous processes are short (1) C3 to C5 are bifurcated Body (2) C7 is a long prominence felt at the back of the • Figure 5-4 Mandible (anterolateral superior view). neck CHAPTER 5 Procedures 101

c. Have small bodies (except for C1 vertebra) 3. Lumbar region (Figure 5-7) d. C1 vertebra (atlas) (Figure 5-5) a. Large and heavy bodies (1) No body b. Four transverse lines separate the bodies of the ver- (2) Anterior and posterior arches and two lateral tebrae on the pelvic surface masses c. Triangular shape: Fitted between the halves of the (3) Superior articular processes join with the con- pelvis dyles of the occipital bone d. Four pairs of dorsal sacral foramina communicate e. C2 vertebra (axis): Process on the upper surface of with four pairs of pelvic sacral foramina the body (dens or odontoid); forms a pivot about 4. Sacral vertebrae which the axis rotates a. Formed by fusion of five sacral segments in curved, 2. Thoracic region (Figure 5-6) triangular bone a. Presence of facets for articulation with the ribs b. Base directed obliquely, superiorly, and anteriorly b. Processes are larger and heavier than processes of c. Apex directed posteriorly and inferiorly the cervical region d. Longer, narrower, and more vertical in males than c. Spinous process is projected downward at a sharp in females angle e. Body of sacrum has sacral promontory, a promi- d. Circular vertebral foramen nent ridge at the upper anterior margin

Atlas (C1): superior view Axis (C2): anterior view

Articular facet Dens Anterior articular Anterior arch for dens facet for atlas Superior Lateral articular Transverse Pedicle process mass facet for atlas Lateral Transverse Vertebral mass foramen foramen Body Transverse Superior articular Posterior arch process facet for occipital Inferior articular facet for C3 condyle Tubercle for transverse ligament Axis (C2): posterosuperior view Dens Atlas (C1): inferior view Superior articular facet for atlas Posterior articular facet Transverse Posterior arch process for transverse ligament Vertebral Lateral foramen mass Transverse Inferior process Transverse foramen articular process Anterior arch Inferior articular Spinous process facet for axis

Cervical vertebra: superior view Body Transverse process Anterior tubercle Transverse foramen Posterior tubercle Pedicle

Vertebral foramen Superior articular facet

Lamina Inferior articular facet Spinous process • Figure 5-5 Distinguishing features of cervical vertebrae. 102 PART 1 Review and Study Guide

Superior view Lateral view

Body Superior Superior articular costal facet process and facet Superior Body Pedicle costal facet Superior vertebral Transverse notch Pedicle costal facet

Transverse Transverse process Superior costal facet articular facet Inferior articular process Inferior costal facet

Inferior Spinous process Vertebral foramen Lamina vertebral notch Spinous process • Figure 5-6 Thoracic vertebra.

Vertebral Sternomanubrial joint foramen Vertebral body Clavicle

Rib 1 Pedicle Transverse process 2 Manubrium 3

4 Superior articular 5 process Lamina 6 Spinous process 7

8 • Figure 5-7 Lumbar vertebra (superior view). 9 Xiphoid process 10 Neck Head 5. Coccygeal vertebrae Tubercle a. Four to five modular pieces fused together Angle Superior Articular facets for vertebral b. Triangular, with the base above and apex below Inferior body F. Defects Articular facet a. Lordosis: Exaggerated lumbar concavity for transverse b. Scoliosis: Lateral curvature of any region process c. Kyphosis: Exaggerated convexity in thoracic region Costal groove

Bones of the Thorax • Figure 5-8 Sternocostal articulations (anterior view); middle rib (posterior view). A. Sternum 1. Forms medial part of the anterior chest wall 2. Manubrium (upper part): Clavicle and first rib articu- B. Ribs—12 pairs (Figure 5-8) late with the manubrium; contains notch on superior 1. Each rib articulates with both the body and the trans- border called jugular (manubrial) notch verse process of its corresponding thoracic vertebra 3. Body (middle blade): Ribs articulate with the body via 2. Second to ninth ribs articulate with the body of the the costal cartilages vertebra above 4. Xiphoid (blunt cartilaginous tip) 3. Ribs curve outward, forward, and then downward CHAPTER 5 Procedures 103

4. Anteriorly, each of the first seven ribs joins a costal c. Curved surface that articulates with the trochlea of cartilage that attaches to the sternum the humerus is the trochlear notch 5. Next three ribs (eighth to tenth) join the cartilage of d. Lateral side concave (radial notch); articulates the rib above with the head of the radius 6. Eleventh and twelfth ribs do not attach to the ster- e. Distal end contains the styloid process num and are called floating ribs D. Hand and wrist (Figure 5-11) 1. Carpal bones—8 Appendicular Skeleton a. Arranged in two rows of four Upper Extremity b. From lateral to medial, proximal row—scaphoid, A. Shoulder: Clavicle and scapula (Figure 5-9) lunate, triquetrum, and pisiform 1. Clavicle c. From lateral to medial, distal row—trapezium, a. Articulates with the manubrium at the sternal end trapezoid, capitate, and hamate b. Articulates with the scapula at the lateral end 2. Metacarpal bones—5 c. Slender S-shaped bone that extends horizontally a. Framework of the hand across the upper part of the thorax b. Numbered 1 through 5, beginning on the lateral side 2. Scapula (see Figure 5-9) 3. Phalanges—14 a. Triangular bone with the base upward and the a. Form the fingers apex downward b. Three phalanges in each finger; two phalanges in b. Lateral aspect contains the glenoid cavity the thumb (fossa), which articulates with the head of the humerus Lower Extremity c. Spine extends across the upper part of the poste- A. Hip (os coxae or innominate) (Figure 5-12) rior surface; expands laterally and forms the acro- 1. Constitutes pelvic girdle mion (point of shoulder) 2. United with the vertebral column d. Coracoid process projects anteriorly from the 3. Union of three parts that is marked by a cup-shaped upper part of the neck of the scapula cavity (acetabulum) B. Humerus 4. Ilium 1. Consists of a shaft (diaphysis) and two ends (epiphyses) a. Prominence of the hip 2. Proximal end has a head that articulates with the gle- b. Superior border is the crest noid cavity (fossa) of the scapula c. ASIS: Projection at the anterior tip of the crest; 3. Greater and lesser tubercles lie below the head just inferior to the ASIS is the anterior inferior a. Intertubercular groove (bicipital groove) is between iliac spine them; long tendon of the biceps attaches here d. Corresponding projections on the posterior part b. Surgical neck is below the tubercles are the posterior superior and posterior inferior 4. Radial groove runs obliquely on the posterior surface; iliac spines radial nerve is here e. Greater sciatic notch: Located beneath the articular 5. Deltoid muscles attach in a V-shaped area in the mid- surface dle of the shaft called the deltoid tuberosity f. Most is a smooth concavity (iliac fossa) 6. Distal end has two projections g. Posteriorly, it is rough and articulates with the a. Capitulum: Lateral, articulates with the radius; sacrum in the formation of the sacroiliac joint expanded area just superior is called the lateral epi- 5. Pubic bone condyle a. Anterior part of the innominate bone b. Trochlea: Medial, articulates with the ulna; expanded b. Symphysis pubis: Joining of the right and left pubic area just superior is called the medial epicondyle bones at the midline C. Forearm (Figure 5-10) c. Body and two rami 1. Radius (1) Body forms one fifth of acetabulum a. Lateral bone of the forearm (2) Superior ramus extends from the body to b. Radial tubercle (tuberosity) located below the the median plane; superior border forms the head on the medial side pubic crest c. Proximal end has disklike head (3) Inferior ramus extends downward and meets d. Neck just inferior to head with the ischium e. Distal end broad for articulation with the wrist (4) Pubic arch is formed by the inferior rami of f. Has styloid process on its lateral side both pubic bones 2. Ulna 6. Ischium a. Medial bone of the forearm a. Forms the lower and back part of the innominate b. Conspicuous part of the elbow joint (olecranon) bone 104 PART 1 Review and Study Guide

Posterior view

Superior notch Clavicle Coracoid process Superior angle Acromion Superior margin Angle of acromion

Medial angle Greater tubercle

Spine Head of humerus

Neck Anatomic neck

Medial margin Surgical neck Lateral margin Inferior angle Deltoid tuberosity Scapula

Humerus Lateral supracondylar crest

Olecranon fossa Medial supracondylar crest Lateral epicondyle Medial epicondyle

Trochlea

Anterior view Coracoid process Acromion Clavicle Anatomic neck Superior angle

Greater tubercle Superior margin

Lesser tubercle Superior notch

Surgical neck Neck

Head Glenoid Medial margin cavity

Deltoid tuberosity Inferior angle Scapula Lateral Lateral supracondylar crest margin Humerus Condyles Medial Medial supracondylar crest Lateral Coronoid fossa Radial fossa Medial epicondyle Lateral epicondyle

Capitulum Trochlea • Figure 5-9 Humerus and scapula. CHAPTER 5 Procedures 105

Radius and ulna in supination: anterior view b. Body (1) Forms two fifths of the acetabulum Olecranon (2) Ischial tuberosity supports the body in a sit- Radial notch of ulna Trochlear notch ting position c. Ramus: Passes upward to join the inferior ramus of Head the pubis Coronoid process d. Opening created by this ring is known as the obtu- Neck rator foramen Tuberosity of ulna B. Pelvis Tuberosity of radius 1. Formed by the right and left hip bones, sacrum, and coccyx 2. Greater pelvis a. Bounded by the ilia and lower lumbar vertebrae b. Gives support to the abdominal viscera 3. Lesser pelvis Radius Ulna a. Brim of the pelvis corresponds to the sacral promontory b. Inferior outlet is bounded by the tip of the coccyx, ischial tuberosities, and inferior rami of the pubic bones 4. Female pelvis a. Shows adaptations related to functions as a birth canal b. Wide outlet c. Angle of the pubic arch is obtuse 5. Male pelvis Styloid process a. Shows adaptations that contribute to power and Styloid process speed • Figure 5-10 Forearm. b. Heart-shaped outlet c. Angle of the pubic arch is acute

Right hand: palmar view Right hand: dorsal view

Scaphoid bone Carpal bones Carpal bones Lunate bone Lunate bone Scaphoid bone Tubercle Triquetral bone Pisiform bone Trapezium bone Pisiform bone Capitate bone and tubercle Hamate bone Triquetral Trapezium bone Trapezoid and hamulus bone bone Metacarpal bones Hamate bone Trapezoid Base bone 1 Metacarpal bones 1 Body Base 2 5 Head 5 2 3 4 Body 4 3 Head

Sesamoid bones Middle Middle phalanges phalanges Proximal Proximal phalanges phalanges

Distal phalanges Distal phalanges • Figure 5-11 Wrist and hand. 106 PART 1 Review and Study Guide

Iliac crest Lateral intercondylar tubercle Medial intercondylar tubercle Lateral Wing (ala) condyle Medial of ilium condyle Apex Body of ilium Head Anterior Neck Tuberosity Posterior superior superior iliac spine iliac spine Anterior inferior Posterior iliac spine inferior iliac spine Acetabulum Greater sciatic Fibula Tibia notch Superior Ischial spine pubic Lesser ramus sciatic notch Inferior Body of pubic ischium ramus Ischial Obturator tuberosity foramen Ramus of ischium • Figure 5-12 Innominate bone (lateral view).

Anterior view Posterior view Lateral Medial malleolus Greater trochanter Greater trochanter Head Head malleolus Trochanteric fossa Inferior articular surface • Figure 5-14 Tibia and fibula (anterior view). Neck Neck

Lesser Lesser Intertrochanteric trochanter trochanter crest D. Patella 1. Sesamoid bone 2. Embedded in the tendon of the quadriceps muscle 3. Articulates with the femur Body E. Leg (Figure 5-14) Body (shaft) (shaft) 1. Tibia: Medial bone a. Proximal end has two condyles that articulate with the femur b. Triangular shaft (1) Anterior: Shin Medial epicondyle (2) Posterior: Soleal line Lateral (3) Distal: Medial malleolus articulates with the epicondyle Lateral lattice that forms the ankle joint Lateral epicondyle condyle Lateral 2. Fibula: Lateral bone condyle a. Articulates with lateral condyle of the tibia but Patellar Intercondylar fossa surface Medial condyle does not enter the knee joint • Figure 5-13 Femur. b. Distal end projects as the lateral malleolus F. Ankle, foot, and toes (Figure 5-15) 1. Adapted for supporting weight, but similar in struc- C. Femur (Figure 5-13) ture to the hand 1. Longest and strongest bone of the body 2. Talus 2. Proximal end has a rounded head that articulates a. Occupies the uppermost and central portion of with the acetabulum the tarsus 3. Constricted portion is neck b. Distributes the body weight from the tibia above 4. Greater and lesser trochanters connected by intertro- to the other tarsal bones chanteric crest 3. Calcaneus (os calcis, heel): Located beneath the talus 5. Slightly arched shaft concave posteriorly 4. Navicular: Located in front of the talus on the 6. Distal end has two condyles separated on the poste- medial side; articulates with three cuneiform bones rior side by the intercondyloid fossa distally CHAPTER 5 Procedures 107

Dorsal view Plantar view Calcaneus Calcaneus Tuberosity Talus Lateral process Trochanter Talus Medial process Neck

Head Head Sustentaculum tali Navicular Navicular bone Cuboid bone Cuboid bone bone Tuberosity Cuneiform bones Tuberosity Metatarsal Lateral Cuneiform bones bones Intermediate Lateral Intermediate Medial 5 Medial Metatarsal bones 5 4 1 2 3 4 3 2 Proximal 1 Sesamoid bones phalanges Lateral Medial

Phalanges Proximal Middle Middle Distal phalanges phalanges Distal phalanges

Lateral view

Navicular bone Cuneiform bones Talus Intermediate Lateral

Metatarsal bones 2 Phalanges Calcaneus 3 Tuberosity 4 5

Tuberosity

Cuboid bone Tuberosity (5th metatarsal)

Medial view

Cuneiform bones Navicular bone Intermediate Talus Medial Metatarsal bones

1 Calcaneus 2

Tuberosity

Tuberosity Sustentaculum (1st metatarsal) Phalanges Sesamoid bone tali • Figure 5-15 Foot. 108 PART 1 Review and Study Guide

5. Cuboid: Lies along the lateral border of the navicular a. Afferent neurons carry the sensory information to bone the CNS 6. Metatarsals b. Efferent neurons carry the motor information a. First, second, and third metatarsals lie in front of away from the CNS the three cuneiform bones 5. Central neurons are found entirely within the CNS; b. Fourth and fifth metatarsals lie in front of the relay information within the system cuboid bone a. Spinal cord is approximately 45.8 cm long; occu- 7. Phalanges pies the upper two thirds of the vertebral canal a. Distal to the metatarsals b. There are 31 pairs of spinal nerves; each has a dor- b. Two in the great toe; three in each of the other sal (afferent) route and a ventral (efferent) route four toes D. Brain is composed of four regions 8. Longitudinal arches of the foot—two 1. Cerebrum a. Lateral: Formed by the calcaneus, talus, cuboid, a. Seat of conscious activities and fourth and fifth metatarsal bones b. Largest portion of the brain b. Medial: Formed by the calcaneus; talus; navicular; c. Superiormost location cuneiform; and first, second, and third metatarsal d. Cerebral cortex: Thin outside layer; gray color; bones composed of several layers of cells; convoluted 9. Transverse arches: Formed by the tarsal and metatarsal surface bones e. Longitudinal fissure: Divides cerebrum into two hemispheres Nervous System* f. Corpus callosum: Heavy band of white fibers; forms the floor of the longitudinal fissure A. Adapts to environmental influences g. Central fissure: Posterior to midline 1. By stimulating skeletal, cardiac, and smooth muscles h. Frontal lobe: Anterior to the central fissure 2. Adaptation by the muscular system is almost i. Parietal lobe: Posterior to the central fissure immediate j. Temporal lobe: Below the lateral fissure B. Organized into different systems k. Occipital lobe: Posterior part of the brain 1. Central nervous system (CNS) l. Broca’s area: Controls the muscular part of speech a. Composed of the brain and spinal cord m. Somesthetic area: Interprets body sensations 2. Peripheral nervous system (PNS) n. Visual area: Fibers from the medial part of the ret- a. Contains the nerves to and from the body wall ina cross to opposite sides in the brain; fibers from that connect to the CNS the lateral portion do not cross b. Also known as the somatic division because it is o. Auditory area: Superior central portion of the tem- under voluntary control poral lobe 3. Autonomic nervous system (ANS) p. Prefrontal area: Personality characteristics a. Not under conscious control (involuntary) 2. Cerebellum: Coordinates balance and equilibrium b. Provides stimulus for the viscera and smooth and 3. Medulla oblongata cardiac muscles a. Bulb of the spinal cord located inside the foramen c. Sympathetic division includes motor (afferent) magnum nerves from the ANS b. White on the outside, gray on the inside d. Parasympathetic division involves motor (efferent) c. Controls three vital functions—cardiac, respira- nerves from the ANS tory, and basal motor C. Nerve cell: Neuron d. Also controls chewing, salivation, swallowing, eme- 1. Dendrite carries impulse toward the cell body under sis, lacrimation, blinking, coughing, and sneezing normal conditions e. Pons: Ropelike mass of white fibers; connects the 2. Axon carries impulse away from the cell body and halves of the cerebellum makes contact with the next cell; release of chemicals 4. Mesencephalon starts impulse in the next neuron a. Short part of the brainstem 3. Myelin sheath: Fatty substance around some cell axons b. Above the pons provides insulation c. Mostly white matter 4. Neurons can carry impulses in different directions E. Meninges: Membranous coverings of the brain and spinal cord 1. Dura mater * The nervous, cardiovascular, and lymphatic systems are not included in the content specifications for the certification exam. Their inclusion here a. Double layer around the brain supports the goal of this text as a study guide for use throughout the radi- b. Single layer around the spinal cord, including the ography program. cauda equina CHAPTER 5 Procedures 109

2. Arachnoid Circulatory System a. Membrane just inside the dura mater A. Overview b. Relatively thin 1. The connection of the heart to the arteries, arterioles, 3. Pia mater capillaries, venules, and veins a. Soft covering that fits against the brain and spinal 2. The system also interacts with the circulatory cord system b. Contains an enormous amount of blood B. Arteries 4. Subarachnoid space 1. Thick-walled elastic vessels a. Threadlike structure through which cerebrospinal 2. End in arterioles fluid circulates C. Arterioles b. Located between the pia mater and arachnoid 1. Smallest branch of an artery F. Cranial nerves 2. Connected to venules by capillaries 1. Part of the PNS D. Capillaries 2. Originate at the base of the brain 1. Connect arterioles to venules 3. 12 pairs of cranial nerves 2. Are lined by a thin layer of endothelium 4. Referred to by name or Roman numerals 3. Capillaries can dilate or constrict, depending on the 5. Provide motor impulses, sensory impulses, or mixed needs of the tissue impulses 4. Red blood cells go through capillaries one cell at a time Heart E. Venules 1. Connected to veins that carry blood toward the heart A. Composed of cardiac muscle; pumps the blood through and carry unoxygenated blood (except in the pulmo- the circulatory system nary vein) B. Located behind the sternum F. Veins C. The size of a human fist 1. Have the same layers as arteries but are thinner D. The apex of the heart points down and to the left 2. Veins collapse without blood E. Located in a space between the lungs and the thoracic 3. Valves in the veins help resist forces of gravity cavity, known as the mediastinum G. Arteriovenous shunt (anastomosis) F. Composed of four chambers—two atria and two ventricles 1. A large blood vessel that connects an artery and vein 1. Blood from the superior and inferior venae cavae directly fills the right atrium and passes into the right ven- 2. Skin color is caused by blood in the capillaries and tricle through the tricuspid valve anastomosis; anastomosis is important for heat G. The unoxygenated blood moves from the right ven- distribution tricle to the lungs through the semilunar valve and the 3. Found only in the hands, face, and toes, where the pulmonary artery body is exposed to weather H. Oxygenated blood is sent from the lungs to the left atrium through the pulmonary veins; the left semilunar Arterial Systemic Circulation valve separates the left atrium from the pulmonary veins A. Aorta I. From the left atrium, blood flows through the mitral 1. Arises from the left ventricle of the heart valve into the left ventricle 2. First 5 cm is called the ascending aorta J. Blood enters circulation by passing through the left 3. Two (left and right) coronary arteries branch off semilunar valve into the aorta directly above the left semilunar valve and supply K. Heart wall consists of three layers blood to the cardiac muscle 1. Visceral pericardium or epicardium B. Aortic arch 2. Myocardium: Heaviest covering 1. Loops back over the top of the heart and left of the 3. Endocardium: Smooth, continuous covering trachea 4. All valves and chambers are lined by endothelium 2. Continues down in back of the heart L. Heartbeat 3. Three arteries come off the arch 1. Averages 70 to 72 beats per minute a. Brachiocephalic 2. Heart cannot contract without nerve impulses (1) Only a few centimeters in length 3. Nerves regulate the rate of the beat (2) Right subclavian artery arises from the bra- M. Cardiac cycle chiocephalic artery and supplies blood to the 1. Consists of a relaxation-contraction cycle right shoulder 2. Lasts for approximately 0.8 second (3) Right common carotid artery arises from the N. Electrocardiogram is a record of the action current as it brachiocephalic artery and supplies blood to travels across the heart the right side of the head 110 PART 1 Review and Study Guide

b. Left common carotid artery supplies blood to the 2. Abdominal aorta left side of the head a. Extends to the L4 vertebra c. Left subclavian artery supplies branches to the b. Gives rise to the visceral and parietal arteries upper chest and scapula c. Celiac artery: Visceral artery that is 1.5 cm long; it C. Carotid arteries divides into several branches 1. Supply the head (1) Left gastric artery: Smallest branch to the 2. Right carotid artery originates from the brachioce- stomach phalic artery (2) Hepatic artery: Supplies most of the blood to 3. Left carotid artery originates from the aortic arch the liver; divides at the liver D. Subclavian arteries (a) Cystic artery: Serves the gallbladder 1. Provide blood to the shoulder and arm (b) Gastric duodenal artery: Divides to serve 2. Left subclavian artery branches from the aortic arch the stomach, pancreas, and duodenum 3. Right subclavian artery branches from the brachioce- (3) Splenic artery: Largest branch to the spleen phalic artery d. Superior mesenteric artery: Supplies all of the small 4. Pass over the first rib and under the clavicle intestine except the duodenum and superior 5. Become the axillary arteries as they pass through the ascending and transverse portion of the colon; shoulder region comes off the front of the aorta below the celiac 6. First branch off the subclavian artery is the vertebral artery artery e. Inferior mesenteric artery: Supplies blood for part E. Vertebral artery of the transverse colon and all of the descending 1. Passes up the neck through the transverse foramen of and sigmoid colon, rectum, and bladder the cervical vertebrae f. Renal artery: Supplies the kidneys; located below 2. Enters the skull through the foramen magnum the superior mesenteric artery 3. The two paired arteries join on the ventral side of the (1) Right renal artery slightly longer and lower medulla and become the basilar artery; this artery because the aorta is slightly left of the midline joins branches from the internal carotid artery to (2) Enters the kidney at the hilus form the circle of Willis, also called the cerebral arte- g. Suprarenal artery: Branches off the aorta above the rial circle renal artery (may be branches of the renal arteries) F. Axillary artery h. Aorta bifurcates and becomes the right and left 1. Becomes the brachial artery at the humerus common iliac arteries 2. Moves along the medial surface across the elbow J. Common iliac arteries bifurcate region and divides into radial and ulnar arteries 1. Internal iliac artery supplies the pelvic wall and G. Radial artery viscera 1. Moves along the radius and crosses it at the distal end 2. External iliac artery goes into the thigh 2. A pulse can be felt at the distal end a. Passes over the pelvic brim and under the inguinal 3. Moves across the metacarpals and deep into the ligament palm b. Becomes the femoral artery 4. Forms a loop that connects with the ulnar artery K. Femoral artery H. Ulnar artery 1. Supplies thigh 1. Travels down the medial surface of the forearm 2. Becomes the popliteal artery just above the knee and 2. Becomes the superficial palmar artery, which joins goes behind the knee to bifurcate with the radial artery a. Anterior tibial artery 3. Digital arteries supply the fingers and branch off from b. Posterior tibial artery the palmar loop c. Anterior and posterior tibial arteries spread out I. Descending aorta: Consists of the thoracic and abdomi- at the ankle and become the dorsal artery of the nal sections of the aorta foot 1. Thoracic aorta a. Starts after the left subclavian artery branches off Venous Systemic Circulation the aortic arch A. Consists of one set of superficial veins and one set of b. Extends from T4–5 to T12–L1 deep veins c. Passes down and in front of the vertebral column B. Veins have a higher blood capacity than arteries but have and through the diaphragm lower blood pressure and velocity d. Gives off several branches supplying the ribs, C. Three sets of veins connect to the heart lungs, and diaphragm 1. Vena cava: Superior and inferior e. After it passes through the diaphragm, it is called a. Serve the body the abdominal aorta b. Return unoxygenated blood CHAPTER 5 Procedures 111

2. Coronary sinus 2. Is constantly moving a. Serves the heart 3. Similar to plasma without large proteins b. Returns unoxygenated blood D. Lymph is tissue fluid that has been reabsorbed into lym- 3. Pulmonary veins phatic vessels a. Serve the lungs (two per lung) E. Valves are necessary in the lymphatic system b. Return oxygenated blood to the left atrium 1. To keep fluid flowing in the right direction D. Superior vena cava 2. Most valves are located in the arms and legs, where 1. Begins at the level of the first rib gravity is a problem 2. Is formed by two veins F. Lymph nodes a. Left and right brachiocephalic veins (return blood 1. Spongy masses of tissue through which lymph from the head, shoulders, and arms) filters b. Each brachiocephalic vein is a union of the inter- 2. Have more afferent vessels leading to the node than nal jugular vein with the subclavian vein efferent vessels leaving the node E. Jugular veins drain blood from the head G. Lymphocytes are small white blood cells that originate 1. External jugular vein from stem cells a. Drains the face and the scalp H. Right lymphatic duct b. Is the union of three main veins that unite just 1. Drains the upper right quadrant of the thorax, right below the ear and empty into the subclavian arm, and right side of the head vein 2. Empties into the right subclavian vein 2. Internal jugular vein I. Thoracic duct a. Returns from the internal carotid vein 1. Drains the rest of the body b. Originates in the skull 2. Begins at the cisterna chyli F. Vertebral veins 3. Passes up the left side of the vertebral column, 1. Arise outside of the skull at the level of the atlas through the aortic hiatus of the diaphragm, and into 2. Pass through the transverse foramen to the subclavian the left subclavian vein artery J. Lymphoid tissue is found in various anatomic structures G. Arms and shoulders are drained by the deep veins that 1. Spleen: The graveyard of red blood cells run alongside the arteries 2. Thymus: Atrophies after puberty but is involved in the H. Inferior vena cava cell-mediated immune system 1. Formed by two common iliac veins at the L5 vertebra 3. Tonsils: Located in the oral cavity in front of the vertebral column I. Azygos vein Respiratory System 1. Branches off the inferior vena cava at the level of the renal veins A. Respiratory tract: Begins at the nostril opening and 2. Goes through the aortic hiatus of the diaphragm just extends to the alveoli of the lungs below the heart B. Air is drawn in through the nose, where it is warmed, 3. Empties into the superior vena cava humidified, and cleansed 4. Picks up veins from the esophagus and bronchi C. Nasal cavity is lined with olfactory epithelium in the J. Other veins serving the abdomen and thorax are named sphenoethmoid recess and by respiratory epithelium in for the region or organs that they serve the lower part K. Veins of the lower extremities D. Superior, middle, and inferior turbinates are located on 1. Deep veins have the same names as the arteries the lateral surface of the nasal cavity 2. Superficial veins E. Frontal, ethmoidal, maxillary, and sphenoidal sinuses a. Great saphenous vein: Drains the dorsalis pedis of empty into the nasal cavity the foot F. Pharynx b. Small saphenous vein: Drains the lateral side of the 1. Second part of the respiratory tract foot 2. Starts at the base of the skull and extends to the c. Popliteal vein: Drains the lateral side of the leg esophagus 3. Divided into three parts Lymphatic System a. Nasopharynx: Behind the nasal cavity (1) Eustachian tube (auditory tube): Connects the A. Carries lymph middle ear with the pharynx; open only dur- B. Involved in the maintenance of fluid pressure ing swallowing; equalizes pressure C. Contains lymph glands that filter foreign particles (2) Pharyngeal tonsils (adenoids): A mass of lym- 1. Tissue fluid is located in the intracellular spaces and is phoid tissue on the upper back wall of the derived from the blood nasopharynx 112 PART 1 Review and Study Guide

b. Oropharynx: Extends from the soft palate to the Q. Pleura: Serous membrane surrounding the visceral and base of the tongue; separated from the oral cavity parietal layers of each lung by the palatine arches 1. Space between the two layers is the pleural cavity c. Laryngopharynx: Extends from the hyoid bone to 2. Lungs are not located in the pleural cavity the larynx R. Mechanics of respiration G. Larynx 1. Involve changing the pressure in the lungs to cause 1. Located at the base of the tongue inspiration or expiration 2. Comprises nine cartilages 2. Inspiration H. Vocal chords a. Occurs when the air pressure in the lungs is 1. Folds of mucous membranes decreased 2. Elastic connective tissue at the edges b. Causes the volume of the lungs to increase I. Trachea c. External intercostal muscles cause the ribs to ele- 1. Approximately 12 cm long vate and increase the size of the chest cavity 2. In front of esophagus d. Dome-shaped diaphragm between the thoracic and 3. Composed of 16 to 20 C-shaped rings that prevent abdominal cavities pulls downward when contracted its collapse e. Also increases the size of the chest cavity 4. At the end of T4 vertebra, the trachea divides into left 3. Expiration and right branches known as the primary bronchi a. Basically a passive movement J. Primary bronchi b. Ribs fall down 1. Left primary bronchus is longer than the right and c. Diaphragm is pushed up by the abdominal viscera forms a sharp angle d. Abdominal muscles force the abdominal contents up 2. Right primary bronchus has a larger diameter than e. Internal intercostal muscles pull the ribs down the left and comes off forming an almost straight line K. Secondary bronchi branch off the primary bronchi Digestive System 1. Three secondary bronchi for the right lung, one per lobe A. Digestive or alimentary tract 2. Two secondary bronchi for the left lung, one per lobe 1. Consists of a tube 6 m long from the mouth to the L. Tertiary bronchi anus 1. Branch off the secondary bronchi 2. Selectively absorbs nutrients and water for the body 2. Each lung has 10 tertiary bronchi because there are B. Mouth 10 segments per lung 1. Site where food processing and digestion begin M. Bronchioles: Smaller branches of the tertiary bronchi 2. Secondary teeth tear and grind the food 1. Terminal bronchioles: Not involved in gaseous exchange C. Tongue 2. Respiratory bronchioles: Branch off the terminal bron- 1. Fibromuscular organ chioles; first site of diffusion of oxygen into the blood 2. Contains the taste buds N. Alveolar ducts 3. Transmits the sensation of taste to the brain 1. Branch off the respiratory bronchioles 4. Rolls the food into a bolus for swallowing 2. Alveolar sacs attach to the alveolar ducts D. Saliva O. Two cone-shaped lungs in the thoracic cavity 1. Added to help food become a bolus for easier passage 1. Base rests on the diaphragm down the esophagus 2. Apex is located at the level of the clavicle 2. Produced by three major paired glands and many 3. Right lung minor glands a. Has three lobes—superior, middle, and inferior E. Salivary glands b. Larger than the left lung 1. Parotid glands 4. Left lung a. Located in the preauricular region a. Smaller than the right lung because two thirds of b. Saliva travels down Stensen’s (parotid) duct, which the heart is located on the left side opens opposite the second maxillary molar b. Contains only two lobes 2. Sublingual glands 5. 10 bronchopulmonary segments per lung a. Lie under the tongue and rest against the mandible a. Each has a branch from the tertiary bronchi b. Saliva travels down Bartholin’s duct and enters b. Used as points of reference for surgery the oral cavity through Rivinus’ (lesser sublingual) P. Cardiac notch: Depression on the medial surface of the ducts on the sublingual fold left lung 3. Submandibular glands 1. Hilus a. Lie on the medial surface of the mandible a. Point of attachment to a lung b. Saliva travels down Wharton’s (submandibular) b. Blood vessels, bronchial tree, and nerves enter at duct and is released into the mouth at the sublin- the hilus gual caruncles CHAPTER 5 Procedures 113

F. Swallowing b. Digests: Secretes pepsin, renin, and gastric lipase 1. Bolus of food moves from the mouth and pharynx to c. Produces hydrochloric acid the esophagus 2. Shaped like the letter “J”; internal surface is wrinkled 2. During swallowing, the soft palate is pushed back (rugae) against the posterior pharyngeal wall, closing the pas- a. Cardiac portion: Esophagus entrance sage to the nasopharynx b. Body: Main part 3. Larynx is elevated; superior opening is protected by c. Fundus: Bulge at the upper end, left of the esopha- the epiglottis geal area 4. Bolus moves into esophagus d. Pyloric portion: Narrow distal end that connects 5. Esophagus: Muscular tube located posterior to the tra- with the small intestine chea and connected to the stomach H. Small intestine: Thin-walled muscular tube 6. Bolus is moved through esophagus by peristalsis and 1. Three portions gravity a. Duodenum (horseshoe-shaped): Bile and pancreatic G. Stomach: Dilated portion of the alimentary canal lying in secretions are added to the small intestine the upper abdomen just under the diaphragm (Figures b. Jejunum (1.5 m long): Greatest amount of absorption 5-16 and 5-17) c. Ileum (2.5 m long): Connects with the large 1. Functions intestine a. Stores food 2. Secretes several enzymes and substances

Left lobe (liver) Lesser omentum Falciform ligament Abdominal esophagus Cardiac notch Fundus Round ligament Diaphragm Quadrate lobe (liver)

Gallbladder

Right lobe

(liver) Cardiac e

u t Spleen a v r Pylorus u c e r r e Body u s t s a v Duodenum e r L u c

Pyloric r te canal a P re y G lo Right kidney ric pa rt o f stomach P ylo ric sinus Greater omentum

Hypersthenic Sthenic Hyposthenic Asthenic

Variations in position and contour of stomach in relation to body habitus • Figure 5-16 Stomach. 114 PART 1 Review and Study Guide

Greater omentum (turned up)

Left lobe Transverse colon of liver (turned up)

Falciform Transverse mesocolon ligament Small intestine Right lobe of liver Stomach Descending colon Gallbladder Sigmoid Greater Ascending colon omentum colon Urinary bladder Cecum

• Figure 5-17 Abdominal viscera.

I. Large intestine: Approximately 1.5 m long and in several 2. Common hepatic duct unites with cystic duct (attached divisions to the gallbladder) to form common bile duct 1. Cecum 3. In some cases, common bile duct joins pancreatic a. Blind pouch in the lower right quadrant duct to enter hepatopancreatic ampulla b. Appendix attaches to cecum 4. Hepatopancreatic ampulla opens into descending c. Ileocecal sphincter separates the ileum from the duodenum cecum 5. In other cases, common bile duct and pancreatic duct 2. Colon enter duodenum directly and separately a. Ascending: From cecum to the hepatic flexure 6. Distal end of common bile duct controlled by hepa- b. Transverse: From hepatic flexure to the splenic topancreatic sphincter (sphincter of Oddi) flexure M. Gallbladder c. Descending: From splenic flexure to the level of the 1. Thin-walled sac with capacity of approximately 2 oz pelvic bone on the left side of the body 2. Concentrates and stores bile and evacuates bile dur- 3. Sigmoid: S-shaped curve ing digestion 4. Rectum: From sigmoid colon down to the pelvic 3. Contraction of gallbladder is controlled by the hor- diaphragm mone cholecystokinin 5. Anus: 3 cm in length J. Pancreas: Exocrine and endocrine gland Urinary System 1. Exocrine a. Produces pancreatic juice that is collected by the A. Kidneys (Figure 5-18) pancreatic (Wirsung’s) duct and carried away 1. Paired, bean-shaped organs on both sides of the ver- b. Joins the common bile duct to form Vater’s (hepa- tebral column topancreatic) ampulla, which penetrates the walls 2. Renal artery and vein and ureter (which leads to the of the abdomen bladder) are attached to the center of the kidney at 2. Endocrine: Releases insulin that controls blood glu- the hilus cose levels; also releases glucagon and somatostatin 3. Outer part of the kidney is called the cortex, and inner K. Liver part is called the medulla 1. Largest and most active gland in the body a. Medulla consists of several pyramids 2. Two main lobes and several lobules b. Apices of the pyramids project into the calyces 3. Lobules produce bile that is carried away and stored c. Nephron is the functional unit of the kidney in the gallbladder 4. Kidneys connected to the bladder by the ureters 4. Stores glycogen B. Ureters 5. Detoxifies waste 1. Approximately 27 cm long 6. Plays major role in metabolism 2. Urine flows down the ureters via peristalsis L. Bile ducts C. Bladder 1. Two main hepatic ducts join to form common hepatic 1. Lies behind the symphysis pubis duct 2. Serves as a reservoir for the urine CHAPTER 5 Procedures 115

Anterior surface Superior extremity Fibrous capsule

Medial margin

Lateral Renal margin artery

Renal vein

Renal pelvis

Medial margin

Ureter

Inferior extremity

Sectioned Cortex Fibrous capsule Medulla (pyramid)

Papilla of pyramid

Renal Medullary sinus rays Major Fat in calyces renal sinus Renal pelvis Blood Minor vessels calyces

Ureter

• Figure 5-18 Kidney.

D. Urethra 2. Filtration rate determined by the filtration pressure 1. Connects the bladder to the exterior 3. Modified as it passes through the tubules by means of 2. Female urethra is approximately 4 cm long reabsorption and secretion 3. Male urethra is approximately 20 cm long a. Proximal convoluted tubule E. Blood is filtered first in the glomeruli b. Loop of Henle 1. Passed through the glomerular membrane into Bow- c. Distal collecting tubule man’s capsule and then into the proximal tubules 4. Waste products are not reabsorbed 116 PART 1 Review and Study Guide

KEY REVIEW POINTS 5. Transverse fracture: Runs at right angle to the long axis of the bone Review of Anatomy Relevant to Radiography 6. Oblique fracture: Runs at approximately a 45-degree angle to the long axis of the bone • Identify, in words or on drawings, the various planes 7. Spiral fracture: Encircles the shaft of the bone and divisions of the body. • As you review the systems of the body, focus on the 8. Avulsion fracture: Small fragments of bone torn off skeletal, respiratory, digestive, and urinary systems. bony prominences These are the systems most often radiographed. 9. Comminuted fracture: Produces more than two • The drawings in the chapter are invaluable. Be certain fragments you can identify the labeled anatomy. 10. Compression fracture: Causes compaction of the bone, resulting in decreased length or width 11. Stress fracture: Results from repeated stresses placed Review of Radiographic Positioning, on the bone Procedures, and Pathology 12. Pathologic fracture: Occurs as a result of bone disease Skeletal System 13. Greenstick fracture: Incomplete fracture with cortex intact on opposite side of the bone from the Pathologic Conditions Imaged* fracture A. Acromegaly 14. Bowing fracture: Occurs when stress applied to 1. Endocrine disorder that causes bones to become thick the bone causes the bone to bow but not fracture and coarse completely 2. Harder to penetrate 15. Undisplaced fracture: Lack of angulation or separa- B. Ankylosing spondylitis tion of fractured bone 1. Inflammatory disease of the spine and adjacent struc- 16. Displacement: Separation of bone fragments tures that causes severe pain and fusion of the joints 17. Angulation: Deformity of the axes of major frag- involved ments of bone C. Bony cyst 18. Dislocation: Displacement of a bone from its normal 1. Fluid-filled sacs in fibrous tissue site of articulation 2. Easier to penetrate 19. Subluxation: Partial loss of continuity in a joint D. Bursitis 20. Fracture healing: Characterized radiographically by 1. Inflammation of bursa; causes severe pain calcium deposits across the fracture line that unite 2. Harder to penetrate if calcium has deposited the fracture fragments E. Callus 21. Battered child syndrome: Multiple fractures at vari- 1. New bony deposit surrounding healing fractures ous stages of healing located in the long bones 2. Harder to penetrate and the skull; also characterized by fractures at F. Clubfoot (talipes) unusual sites (e.g., ribs, scapula, sternum, spine, 1. Congenital malformation of the foot that causes the and clavicles) foot to turn in at the ankle 22. Colles fracture: Transverse fracture through the distal G. Congenital hip anomaly radius with posterior angulation and overriding of 1. Caused by malformation of the acetabulum in which the distal fracture fragment the femoral head displaces superiorly and posteriorly 23. Boxer fracture: Transverse fracture of neck of the H. Disk herniation fifth metacarpal with palmar angulation of the distal 1. Protrusion of an intervertebral disk fragment I. Ewing’s sarcoma 24. Elbow fractures: In addition to bony involvement, 1. Malignant, destructive tumor of bone marrow image shows dislocation of elbow fat pads; this 2. Easier to penetrate necessitates the use of appropriate radiographic J. Fractures: Disruption of bone tissue exposure 1. Complete fracture: Discontinuity between two or 25. Pott fracture: Fracture of medial and lateral malleoli more fragments of the ankle with ankle joint dislocation 2. Incomplete fracture: Partial discontinuity; portion of 26. Bimalleolar fracture: Fracture of both medial and the cortex is intact lateral malleoli 3. Closed fracture: Overlying skin is intact 27. Trimalleolar fracture: Fracture of the posterior por- 4. Compound fracture: Overlying skin is broken; bony tion of the tibia and the medial and lateral malleoli fragments 28. Jefferson fracture: Comminuted fracture of the ring of the atlas, involving both anterior and * Designation of “harder to penetrate” or “easier to penetrate” does not posterior arches and causing displacement of the signify that alteration of exposure technique is required. fragments CHAPTER 5 Procedures 117

29. Hangman fracture: Caused by acute hyperextension 1. Abnormal demineralization of bone of the head on the neck; characterized by fracture of 2. Easier to penetrate the arch of C2 and anterior subluxation of C2 onto Z. Paget disease (osteitis deformans) C3; caused primarily by motor vehicle accidents 1. Nonmetabolic bone disease causing bone destruction 30. Seat belt fracture: Transverse fracture of lumbar ver- and unorganized bone repair tebrae in addition to substantial abdominal injuries 2. Difficult to image properly because some areas that K. Hydrocephalus are easier to penetrate are adjacent to structures that 1. Abnormal accumulation of cerebrospinal fluid in the are harder to penetrate brain AA. Rheumatoid arthritis 2. Harder to penetrate 1. Destructive collagen disease with inflammation and L. Giant cell myeloma joint swelling 1. Benign or malignant tumor arising on bone with 2. Harder to penetrate large bubble appearance BB. Rickets 2. Easier to penetrate 1. Soft, pliable bones resulting from deficiency of vita- M. Gout min D and sunlight 1. Metabolic disorder in which urate crystals are depos- 2. Easier to penetrate ited in the joints, most commonly the great toe, and CC. Scoliosis cause extreme swelling 1. Abnormal lateral curvature of the spine 2. Harder to penetrate DD. Spina bifida N. Multiple myeloma 1. Defect of posterior aspect of spinal canal caused by 1. Malignancy of plasma cells resulting in destruction failure of vertebral arch to form properly of bone, failure of bone marrow, and impairment of EE. Spondylolysis renal function 1. Defect in pars articularis, which is between the supe- 2. Easier to penetrate rior and inferior articular processes of a vertebra O. Osteoarthritis 2. No displacement present 1. Form of arthritis characterized by degeneration of FF. Spondylolisthesis one or several joints 1. Spondylolysis with displacement 2. Easier to penetrate P. Osteoblastic metastases Digits (Fingers) 1. Dense, sclerotic tumors in bone A. PA 2. Harder to penetrate 1. Patient position: Seated Q. Osteochondroma 2. Part position: Separate and center extended digit of 1. Benign projection of bone in the young interest with palmar surface of hand firmly against 2. Harder to penetrate image receptor R. Osteogenic sarcoma 3. Central ray: Perpendicular, entering proximal inter- 1. Destructive cancer at the end of long bones phalangeal joint 2. Easier to penetrate (except for sclerotic area) B. Lateral S. Osteoma 1. Patient position: Seated 1. Benign, small, round tumor 2. Part position 2. Harder to penetrate a. Extend digit of interest T. Osteogenesis imperfecta b. Close rest of digits into a fist 1. Inherited condition causing poor development of c. Adjust digit of interest parallel to image receptor connective tissue and brittle, easily fractured bones plane 2. Easier to penetrate d. Immobilize extended digit U. Osteomyelitis 3. Central ray: Perpendicular, entering proximal inter- 1. Bacterial infection of bone and bone marrow phalangeal joint 2. Easier to penetrate C. Oblique V. Osteolytic metastases 1. Patient position: Seated 1. Arise in medullary canal to destroy bone 2. Part position 2. Easier to penetrate a. Place patient’s hand in lateral position, ulnar side W. Osteomalacia down 1. Abnormal softening of bone b. Center to image receptor 2. Easier to penetrate c. Rotate palm 45 degrees toward image receptor X. Osteopetrosis until digits are resting on support 1. Inherited condition causing increased bone density d. Immobilize separated digits 2. Harder to penetrate 3. Central ray: Perpendicular, entering proximal inter- Y. Osteoporosis phalangeal joint 118 PART 1 Review and Study Guide

Thumb A. AP, lateral, oblique 1. Patient position: Seated 2. Part position a. AP: Patient’s hand is turned in extreme internal rotation, thumb resting on image receptor and other fingers held out of the way 2 3 b. Lateral: Hand in natural, arched position, palm 4 1 down; adjust hand to put thumb in true lateral 5 position c. Oblique: Abduct thumb, palm down 3. Central ray (all projections): Perpendicular to metacar- G pophalangeal joint P H C Hand S A. PA T Ulnar L 1. Patient position: Seated styloid 2. Part position process a. Patient rests forearm on table with palmar surface Radial styloid firmly against image receptor process b. Spread digits slightly 3. Central ray: Perpendicular to third metacarpophalangeal joint B. Oblique 1. Patient position: Seated, forearm resting on table with • Figure 5-19 PA wrist. C, Capitate; G, trapezium; H, hamate; L, hand on image receptor in lateral position, ulnar side lunate; P, pisiform; S, scaphoid; T, triquetrum. down 2. Part position a. Rotate hand medially b. Place digits on a 45-degree radiolucent support to show interphalangeal joints 1st metacarpal c. Adjust digits parallel to image receptor 3. Central ray: Perpendicular to third metacarpophalangeal joint C. Lateral Trapezium 1. Patient position: Seated, resting ulnar surface of forearm on table with hand in true lateral position Scaphoid 2. Part position a. Extend digits with first digit (thumb) placed at a Capitate right angle to palm of hand b. As an option, patient may “fan” fingers and place Lunate on positioning sponge to reduce superimposition of phalanges Radius c. Center metacarpophalangeal joints to image receptor Ulna d. Adjust palmar surface of hand perpendicular to image receptor • Figure 5-20 Lateral wrist. 3. Central ray: Perpendicular to second metacarpophalangeal joint 3. Central ray: Perpendicular to midcarpal area Wrist (Figure 5-19) A. PA B. Lateral 1. Patient position: Seated, forearm resting on table 1. Patient position: Elbow is flexed 90 degrees, with fore- 2. Part position arm and arm in contact with table a. Center carpus to image receptor area 2. Part position: Center carpals and adjust hand so wrist b. Digits are flexed slightly to place wrist in contact is in a lateral position with image receptor 3. Central ray: Perpendicular to wrist joint (Figure 5-20) CHAPTER 5 Procedures 119

Medial epicondyle Lateral epicondyle Epiphysis Radial head 1st metacarpal Radial neck Radial tuberosity

Trapezium

Scaphoid Ulnar body Lunate Radial body

Radius

Ulna

• Figure 5-21 PA oblique wrist.

C. Oblique 1. Patient position: Seated, ulnar surface of wrist on image receptor 2. Part position a. Center carpus to image receptor area Radial styloid process . b F rom true lateral position, rotate part approximately 45 degrees medially and support on • Figure 5-22 AP forearm with fractured radius and ulna. sponge 3. Central ray: Perpendicular to image receptor, entering c. Center forearm to image receptor to include joints midcarpal area just distal to radius (Figure 5-21) of interest D. Scaphoid (navicular) 3. Central ray: Perpendicular to midpoint of forearm 1. Patient position: Elbow is flexed 90 degrees, with fore- (Figure 5-23) arm and arm in contact with table 2. Part position Elbow a. Center carpals to image receptor area A. AP . b P lace patient’s wrist in extreme ulnar flexion 1. Patient position: Seated, with arm extended 3. Central ray: Perpendicular to scaphoid; option to 2. Part position delineate fracture may require angulation of 10 to a. Extend patient’s elbow 15 degrees proximally (toward elbow) or distally; . b Supinate hand another approach is to elevate distal end of image c. Center elbow joint to image receptor receptor approximately 20 degrees d. Patient may have to lean slightly laterally to ensure AP alignment Forearm 3. Central ray: Perpendicular to elbow joint (Figure 5-24) A. AP B. Lateral 1. Patient position: Seated 1. Patient position: Seated, with elbow flexed 90 degrees; 2. Part position: Supinate hand and center forearm to humerus and forearm resting on table image receptor to include joints of interest 2. Part position 3. Central ray: Perpendicular to midpoint of forearm . a Center 90-degree flexed elbow joint to image receptor (Figure 5-22) . b Adjust wrist and hand in lateral position B. Lateral 3. Central ray: Perpendicular to elbow joint (Figure 5-25) 1. Patient position: Seated, with humerus and forearm in C. Medial oblique contact with table; elbow flexed 1. Patient position: Seated, with arm extended 2. Part position 2. Part position a. E lbow is flexed 90 degrees a. Pronate hand . b A djust hand to lateral position (thumb up) . b Medially rotate arm 120 PART 1 Review and Study Guide

Olecranon process Humeral epicondyle Coronoid process

Radial head

Radial tuberosity Humeral Radial epicondyles head Olecranon process

Radial neck Coronoid process Ulnar body Radial body

• Figure 5-25 Lateral elbow.

Ulnar styloid process

• Figure 5-23 Lateral forearm.

Olecranon process Olecranon fossa Medial epicondyle Trochlea Coronoid process

Lateral Medial epicondyle epicondyle Capitulum Trochlea Radial head Proximal ulna Radial neck • Figure 5-26 AP oblique elbow.

a. Rotate patient’s hand laterally b. Adjust posterior surface of elbow at a 40-degree angle to image receptor 3. Central ray: Perpendicular to elbow joint • Figure 5-24 AP elbow. Humerus c. Adjust anterior surface of elbow (epicondyles) at A. AP angle of 40 to 45 degrees 1. Patient position: Erect or supine 3. Central ray: Perpendicular to elbow joint (Figure 5-26) 2. Part position D. Lateral oblique a. Unless it is contraindicated, supinate patient’s 1. Patient position: Seated, with arm extended hand and adjust humerus with epicondyles par- 2. Part position allel to image receptor; keep humerus in neutral CHAPTER 5 Procedures 121

Greater tubercle

Clavicle Acromion

Acromioclavicular joint

Acromion Coracoid process Head

Lesser tubercle Body of scapula Glenoid cavity

Inferior angle • Figure 5-27 AP shoulder.

Humerus position if fracture is suspected or if reexamining healing fracture with a hanging cast • Figure 5-28 PA oblique shoulder (scapular Y). b. If patient is recumbent, elevate and support opposite shoulder c. Center humerus to image receptor to image receptor; central ray perpendicular to 3. Central ray: Perpendicular to midpoint of humerus median coronal plane, exiting surgical neck of B. Lateral affected humerus; if patient cannot elevate unaf- 1. Patient position: Erect or supine fected shoulder, the central ray may be angled 10 2. Part position to 15 degrees cephalad a. Unless it is contraindicated, slightly abduct the C. PA oblique (scapular Y) arm and center arm to image receptor 1. Patient position: Erect or prone oblique b. Medially rotate forearm until epicondyles are per- 2. Part position pendicular to image receptor a. Center anterior surface of affected shoulder to 3. Central ray: Perpendicular to midpoint of humerus image receptor b. Rotate patient so that midcoronal plane forms a Shoulder 60-degree angle from image receptor A. AP c. Respiration: Suspended 1. Patient position: Erect or supine 3. Central ray: Perpendicular to shoulder joint at level of 2. Part position scapulohumeral joint (Figure 5-28) a. Center area of coracoid process to image receptor Acromioclavicular Articulations b. Rotate patient slightly to place affected scapula A. AP parallel to image receptor 1. Patient position: Upright if condition permits c. Adjust hand in (1) external rotation to obtain AP 2. Part position projection of humerus or (2) internal rotation for a. Adjust midpoint of image receptor to level of acro- lateral position of humerus mioclavicular (AC) joints d. Respiration: Suspended b. Center MSP of patient’s body to midline of image 3. Central ray: Perpendicular to coracoid process receptor, if both AC joints can be shown on one (Figure 5-27) image B. Transthoracic lateral c. Otherwise, center to each individual AC joint for 1. Patient position: Erect or supine two separate exposures 2. Part position d. To show AC separation, sandbags of equal weight a. Raise uninjured arm and rest on head should be attached to each wrist, and a second b. Elevate uninjured shoulder as much as possible image should be obtained without weights c. Respiration: Full inspiration or slow breathing e. Respiration: Suspended 3. Central ray: Adjust patient to project humerus between 3. Central ray: Perpendicular to image receptor, mid- vertebral column and sternum; unless it is contrain- way between AC joints or perpendicular to each AC dicated, adjust humeral epicondyles perpendicular joint 122 PART 1 Review and Study Guide

Clavicle B. Oblique A. PA 1. Patient position: Supine or seated on table, knees 1. Patient position: Erect or prone; may be AP for patient flexed with feet separated comfort 2. Part position: Center patient’s toes over image recep- 2. Part position tor area and medially rotate leg and foot until a 30- . a Center clavicle to center of image receptor midway to 45-degree angle is formed from image receptor to between midline of body and coracoid process plantar surface of foot . b Head may be turned away from affected side 3. Central ray: Perpendicular, entering third metatarso- c. Respiration: Suspended phalangeal joint 3. Central ray: Perpendicular to midshaft of clavicle B. PA axial Foot 1. Patient position: Erect or prone; may be supine (AP A. AP axial axial) for patient comfort 1. Patient position: Supine or seated on table, knees 2. Part position flexed with feet separated . a Center clavicle to midline of table with image recep- 2. Part position tor midway between MSP and coracoid process a. Plantar surface firmly resting on image receptor . b Head may be turned away from affected side . b Center foot to image receptor c. Respiration: Suspended c. Adjust midline of foot parallel to long axis of 3. Central ray: Angle 25 to 30 degrees caudad, centered image receptor to the midshaft of the clavicle (25 to 30 degrees ceph- 3. Central ray: 10 degrees toward the heel, entering base alad if performed AP) of third metatarsal B. Medial oblique Scapula 1. Patient position: Supine or seated on table, knees flexed A. AP with feet separated 1. Patient position: Supine or upright (upright preferred 2. Part position when shoulder is tender) a. Center foot to image receptor 2. Part position . b Rotate leg medially until plantar surface forms a. Abduct arm angle of 30 degrees to image receptor . b Flex elbow 3. Central ray: Perpendicular to base of third metatarsal c. Support hand near head (Figure 5-30) . d Center palpated scapular area to image receptor approximately 2 inches inferior to coracoid process e. Respiration: Quiet breathing 3. Central ray: Perpendicular to image receptor at mid- Acromion scapular area approximately 2 inches inferior to coracoid process (Figure 5-29) Clavicle B. Lateral 1. Patient position: Prone oblique or upright (upright preferred when shoulder is tender) Coracoid 2. Part position process a. Place patient in an oblique position with affected Glenoid scapula centered to image receptor cavity . b Extend affected arm across anterior thorax c. Palpate axillary and vertebral borders of scapula Lateral and adjust body rotation so that scapula is lateral border of scapula and is projected free of rib cage d. Respiration: Suspended 3. Central ray: Perpendicular to medial border of pro- truding scapula Medial border Toes of scapula A. AP axial 1. Patient position: Supine or seated on table, knees flexed with feet separated 2. Part position: Center toes with plantar surface flat Inferior against image receptor angle 3. Central ray: 15 degrees cephalad, if positioning wedge is of scapula not used; enters the second metatarsophalangeal joint • Figure 5-29 AP scapula. CHAPTER 5 Procedures 123

C. Lateral (mediolateral) Calcaneus 1. Patient position A. Axial (plantar dorsal) a. With the patient lying on the affected side, adjust 1. Patient position: Supine or seated with leg fully extended leg and foot in lateral position 2. Part position b. Patella perpendicular to table a. Center image receptor to ankle 2. Part position: Center foot and adjust plantar surface b. Draw the plantar surface of foot perpendicular to perpendicular to image receptor image receptor 3. Central ray: Perpendicular to midpoint of image 3. Central ray: 40 degrees cephalad to long axis of foot, receptor, entering base of third metatarsal entering midline at level of base of fifth metatarsal B. Lateral 1. Patient position a. With the patient lying on the affected side, adjust leg and foot in lateral position b. Patella perpendicular to table Medial 2. Part position: Center calcaneus to image receptor, cuneiform about 1 to 1½ inches distal to medial malleolus C. Central ray: Perpendicular to midportion of calcaneus Intermediate cuneiform Ankle A. AP 2 1 3 1. Patient position: Supine or seated on table with small 4 support under knee 5 2. Part position Metatarsals a. Center ankle to image receptor b. Dorsiflex foot c. Adjust ankle with toes pointing vertically 3. Central ray: Perpendicular to ankle joint midway Tuberosity between malleoli (Figure 5-31) Lateral B. Lateral cuneiform Cuboid 1. Patient position: Supine; roll onto affected side 2. Part position Calcaneus a. Rotate patient’s ankle to lateral position b. Adjust foot in lateral position Navicular Talus Sinus tarsi c. Center ankle to image receptor • Figure 5-30 AP oblique foot in medial rotation. 3. Central ray: Vertical through medial malleolus (Figure 5-32)

Tibia Fibula

Medial Tibiotalar joint malleolus

Lateral malleolus Talus

• Figure 5-31 AP ankle. 124 PART 1 Review and Study Guide

Patella Tibia Femoral condyles Fibula

Tibiotalar joint

Talus

Tibia Navicular Fibula

Cuboid

Calcaneus

• Figure 5-32 Lateral ankle.

Medial C. Medial oblique malleolus 1. Patient position: Supine or seated on table 2. Part position a. Rotate patient’s leg and foot medially • Figure 5-33 Lateral tibia and fibula. b. Adjust degree of medial rotation (1) Mortise joint: Until malleoli are parallel with image receptor (15 to 20 degrees) a. Center knee to image receptor (2) Bony structure: Up to 45 degrees rotation b. Adjust leg to AP position 3. Central ray: Vertical midway between malleoli 3. Central ray: 5 to 7 degrees cephalad to a point ½ inch inferior to patellar apex (Figure 5-34) Leg B. Lateral A. AP 1. Patient position: Turn patient onto affected side with 1. Patient position: Supine with leg extended knee flexed (usually 20 to 30 degrees) 2. Part position 2. Part position a. Center leg to image receptor a. Flex and center knee b. Adjust leg to AP position b. Center image receptor approximately 1 inch distal c. Both joints should be included to medial epicondyle 3. Central ray: Vertical to midpoint of leg c. Patella perpendicular to image receptor B. Lateral 3. Central ray: 5 degrees cephalad, entering knee joint 1. Patient position: Supine and roll onto affected side inferior to medial condyle 2. Part position C. Intercondylar fossa (tunnel) a. Center leg to image receptor 1. Patient position: Kneeling on radiographic table with b. Adjust leg to lateral position affected knee flexed 70 degrees from full extension c. Patella perpendicular 2. Part position d. Both joints should be included a. Center knee to image receptor 3. Central ray: Perpendicular to midpoint of leg b. Place at level of patellar apex (Figure 5-33) c. Flex knee 70 degrees from full extension 3. Central ray: Perpendicular to long axis of lower leg, Knee entering midpopliteal area A. AP 1. Patient position: Supine and with leg extended; adjust Patella patient’s body so that pelvis is not rotated A. PA 2. Part position 1. Patient position: Prone with knee extended CHAPTER 5 Procedures 125

Medial epicondyle Femur

Patella Lateral epicondyle

Lateral condyle Medial condyle

Lateral tibial plateau Medial tibial plateau

Intercondylar eminence

Head of fibula Tibia

Fibula

• Figure 5-34 AP knee.

Patella

Patellofemoral articulation Lateral femoral condyle Medial femoral condyle

Fibula

• Figure 5-35 Tangential patella (Settegast method).

2. Part position 2. Part position: Flex knee 5 to 10 degrees, femoral epi- a. Center patella condyles superimposed b. Adjust to be parallel with image receptor plane 3. Central ray: Perpendicular to patella c. Heel generally rotated 5 to 10 degrees laterally 3. Central ray: Perpendicular to midpopliteal area Femur B. Tangential A. AP 1. Patient position: Prone with foot resting on table 1. Patient position: Supine with toes up 2. Part position: Flex affected knee so that tibia and fib- 2. Part position ula form a 50- to 60-degree angle from table a. Center affected thigh to midline of table 3. Central ray: 45 degrees cephalad through patellofem- b. Internally rotate lower limb approximately 15 degrees oral joint (Figure 5-35) c. Both joints should be included C. Lateral d. Apply gonadal shielding as appropriate 1. Patient position: Lying on affected side 3. Central ray: Perpendicular to midfemur 126 PART 1 Review and Study Guide

B. Lateral B. Lateral 1. Patient position: Lying on affected side with knee 1. Patient position: From supine position, turn patient slightly flexed toward affected side to posterior oblique body 2. Part position position a. Rotate patient’s unaffected hip (including hip 2. Part position joint) posteriorly to prevent superimposition of a. Flex affected knee unaffected hip b. Center affected hip to midline of table b. Center femur to midline of table c. Extend unaffected knee c. Both joints should be included d. Respiration: Suspended d. Apply gonadal shielding as appropriate 3. Central ray: Perpendicular to a point midway between 3. Central ray: Perpendicular to midfemur ASIS and symphysis pubis C. Axiolateral Pelvis 1. Patient position: Supine with level of greater trochan- A. AP ter elevated to center of image receptor 1. Patient position: Supine 2. Part position 2. Part position a. Flex knee and hip of unaffected side a. Center MSP to table b. Elevate and rest on suitable support b. Adjust to AP position c. Adjust pelvis to supine position c. Internally rotate feet and lower limb 15 degrees d. Unless it is contraindicated, rotate affected leg 15 d. Center image receptor approximately 2 inches to 20 degrees internally superior to level of greater trochanter e. Respiration: Suspended e. Use gonadal shielding as appropriate 3. Central ray: Perpendicular to long axis of femoral f. Respiration: Suspended neck and image receptor 3. Central ray: Perpendicular to midpoint of image receptor 2 inches superior to symphysis pubis Cervical Vertebrae A. Atlas and axis Hip 1. Patient position: Erect or supine A. AP 2. Part position 1. Patient position: Supine a. MSP centered to image receptor at level of C2 2. Part position b. Arms by sides a. Rotate lower limb 15 degrees medially c. Shoulders in same plane b. Center hip to image receptor d. Have patient open mouth wide c. Respiration: Suspended e. Adjust head so that line from lower edge of upper 3. Central ray: Perpendicular to a point 2 inches medial incisors to mastoid process is perpendicular to to ASIS and at level of superior margin of greater tro- image receptor chanter (Figure 5-36) f. Respiration: Phonate “ah” during exposure 3. Central ray: Perpendicular to image receptor, centered to open mouth (Figure 5-37) B. AP axial 1. Patient position: Erect or supine Ilium

Acetabulum Occipital base

Femoral head Occlusal surface Greater of teeth trochanter Femoral neck Dens (odontoid Pubic process) symphysis Mandibular ramus Lesser trochanter Lateral mass of atlas Inferior articular process of atlas Femoral body Spinous process of axis • Figure 5-36 AP hip. • Figure 5-37 Open-mouth atlas and axis. CHAPTER 5 Procedures 127

2. Part position e. Obtain both oblique projections a. MSP centered to image receptor f. Respiration: Suspended b. Arms by sides 3. Central ray: 15 to 20 degrees cephalad, entering C4 c. Center image receptor at level of C4 (Figure 5-40) d. Adjust a line between upper occlusal plane and mastoid tip, perpendicular to image receptor Thoracic Vertebrae e. Respiration: Suspended A. AP 3. Central ray: 15 to 20 degrees cephalad, entering 1. Patient position: Supine or upright slightly inferior to thyroid cartilage (Figure 5-38) 2. Part position C. Lateral a. MSP centered to image receptor 1. Patient position: Seated or standing in lateral position b. Top of image receptor 1½ to 2 inches above shoul- 2. Part position ders a. Center coronal plane through mastoid tips to c. Arms by sides image receptor d. Shoulders in same plane b. Adjust patient’s shoulders to same horizontal level e. Respiration: Shallow or suspended expiration and body to true lateral position 3. Central ray: Perpendicular to T7, 3 to 4 inches distal c. Elevate chin slightly to jugular (manubrial) notch d. Relax shoulders B. Lateral e. Weights may be attached to wrists to help lower 1. Patient position: Lateral recumbent or erect shoulders 2. Part position f. Source-to-image receptor distance (SID) recom- a. Elevate head to spine level mended—72 inches b. Extend arms forward g. Respiration: Expiration c. Place radiolucent support under lower thoracic 3. Central ray: Perpendicular to image receptor entering region until spine is horizontal to top of table C4 (Figure 5-39) d. Respiration: Shallow or suspended expiration D. LPO and RPO (AP axial oblique projections) 3. Central ray: Perpendicular to image receptor, entering 1. Patient position: Seated or standing level of T7, approximately 3 to 4 inches below sternal 2. Part position angle (Figure 5-41) a. Rotate body 45 degrees C. Cervicothoracic (twining) b. Place side of interest farther from image receptor 1. Patient position: Lateral, seated, or standing c. Have patient slightly extend chin while looking 2. Part position forward a. Center midcoronal plane to grid d. Center spine to image receptor b. Elevate arm adjacent to Bucky c. Center image receptor to level of T2

Occipital bone Mandibular rami

Body of C3 C4

Inferior articular process Intervertebral disk space Superior articular C5 process Spinous process 7th cervical Intervertebral disk

Zygapophyseal joint

Vertebra prominens

• Figure 5-38 AP axial cervical vertebrae. • Figure 5-39 Lateral cervical vertebrae. 128 PART 1 Review and Study Guide

Mandible

Intervertebral foramen

Pedicle of C5

Intervertebral disk space C5-C6 C7

• Figure 5-40 RAO showing right side.

d. Body in true lateral position e. Respiration: Suspended 3. Central ray: Perpendicular to image receptor, entering at level of T2 (Figure 5-42)

T5 Lumbar Vertebrae A. AP 1. Patient position: Supine 2. Part position a. MSP centered to table b. Flex patient’s knees and hips enough to place back in firm contact with table c. Center image receptor at level of iliac crest (L4) d. Respiration: Suspended Intervertebral 3. Central ray: Perpendicular to midline, entering level disk space of iliac crests (Figure 5-43) Vertebral B. Lateral body 1. Patient position: Lateral with hips and knees flexed T11 2. Part position Intervertebral foramen a. Center midaxillary line of body and L4 to table b. Extend arms forward c. Place radiolucent support under lower thorax, and adjust spine parallel to table 12th rib L1 d. Check for true lateral position e. Respiration: Suspended 3. Central ray: Perpendicular to image receptor, entering • Figure 5-41 Lateral thoracic spine. midaxillary line at level of iliac crests (Figure 5-44) C. Lateral L5 to S1 1. Patient position: Lateral with hips and knees flexed 2. Part position CHAPTER 5 Procedures 129

Elevated clavicle

Elevated humerus

Depressed clavicle

• Figure 5-42 Lateral cervicothoracic region (twining method).

T12

L1 T12 12th rib

Intervertebral disk space

Pedicle Body L2 Lumbar body

Intervertebral disk Transverse Lamina space process

Spinous Intervertebral foramen process

Sacroiliac L4 joint

Crest of ilium

Lumbosacral interspace

Sacrum

• Figure 5-43 AP lumbar spine. • Figure 5-44 Lateral lumbar spine.

a. Center 1½ inches posterior to midaxillary line and spine cannot be placed in a true horizontal position, 1½ inches below iliac crest may need to angle central ray caudally—5 degrees in b. Extend arms forward male patients, 8 degrees in female patients) c. Place radiolucent support under lower thorax, and D. LPO and RPO (AP oblique projections) adjust spine parallel to table 1. Patient position: Posterior oblique; side closest to d. Check for true lateral position image receptor is side of interest e. Collimate tightly 2. Part position f. Respiration: Suspended a. Adjust and support body obliquity to 45 degrees 3. Central ray: Perpendicular to a point 2 inches poste- b. Adjust arms to a comfortable position rior to ASIS and 1½ inches inferior to iliac crest (if c. Center spine to midline of table 130 PART 1 Review and Study Guide

d. Center image receptor at level of L3 3. Central ray: Perpendicular to image receptor, enter- e. Obtain oblique projections of both sides ing palpated coccyx located approximately 5 inches f. Respiration: Suspended posterior to median coronal plane 3. Central ray: Perpendicular to L3, 1 to 2 inches above level of iliac crest, entering elevated side 2 inches lat- Scoliosis Series erally from patient’s midline A. PA (to minimize exposure to breast tissue; AP may be performed with compensating filters) Sacroiliac Joints 1. Patient position: Seated or standing A. LPO and RPO (AP oblique) 2. Part position 1. Patient position: Supine a. First image: MSP centered to image receptor; 2. Part position image receptor adjusted to include 1 inch of the a. Elevate and support side of interest 25 to 30 iliac crests; arms at sides degrees from table b. Second image: MSP centered to image receptor; b. Align sagittal plane passing 1 inch medial to ASIS elevate hip or foot to convex side of curve 3 or of elevated side centered to image receptor 4 inches on a block c. Center to table 3. Central ray: Perpendicular to the midpoint of the d. Obtain both oblique projections image receptor e. Respiration: Suspended Thorax 3. Central ray: Perpendicular to image receptor, 1 inch medial to elevated ASIS Pathologic Conditions Imaged A. Adult respiratory distress syndrome Sacrum 1. Acute life-threatening respiratory distress A. AP axial 2. Large amount of fluid in interstitial and alveolar spaces 1. Patient position: Supine 3. Harder to penetrate 2. Part position B. Asthma a. Center MSP to center of table 1. Pulmonary disorder with increased mucus produc- b. Respiration: Suspended tion in bronchi, causing hyperventilation of the lungs 3. Central ray: 15 degrees cephalad, entering 2 inches 2. Bronchi harder to penetrate superior to symphysis pubis 3. Lungs easier to penetrate B. Lateral C. Atelectasis 1. Patient position: Lateral with hips and knees flexed 1. Collapse of lung tissue 2. Part position 2. Harder to penetrate a. Support body to place long axis of spine hori- D. Bronchial adenoma zontally 1. Neoplasm occurring in a bronchus, causing atelecta- b. Align coronal plane, passing 3 inches posterior to sis and pneumonitis median coronal plane 2. Harder to penetrate c. Center to midline of table E. Bronchiectasis d. Respiration: Suspended 1. Dilation and destruction of bronchial walls 3. Central ray: Perpendicular to image receptor, entering 3 2. Consolidation present inches posterior to median coronal plane at level of ASIS 3. Harder to penetrate F. Bronchogenic carcinoma Coccyx 1. Lung cancer arising from the bronchial mucosa A. AP axial 2. Harder to penetrate 1. Patient position: Supine G. Chronic bronchitis 2. Part position 1. Debilitating pulmonary disease with substantial a. Center MSP to center of table increase of mucus production in the trachea and b. Respiration: Suspended bronchi 3. Central ray: 10 degrees caudad, entering 2 inches 2. Harder to penetrate unless evolved into emphysema, superior to symphysis pubis which is easier to penetrate B. Lateral H. Chronic obstructive pulmonary disease (COPD) 1. Patient position: Lateral with hips and knees flexed 1. Progressive condition marked by diminished capa- 2. Part position bilities of inspiration and expiration a. Support body to place long axis of spine horizontally 2. Harder to penetrate b. Align coronal plane passing approximately 5 I. Croup inches posterior to median coronal plane 1. Acute viral infection of respiratory system in infants c. Center to midline of table 2. Lateral soft tissue neck image taken to show epiglottic d. Respiration: Suspended narrowing CHAPTER 5 Procedures 131

J. Cystic fibrosis b. Back of hands on hips 1. Inherited pathologic condition of exocrine glands c. Top of image receptor 1 to 2 inches above relaxed 2. Marked by increased mucus secretion in lungs and shoulders bronchi 2. Part position 3. Harder to penetrate a. MSP centered K. Emphysema b. Chin extended and pointing straight ahead 1. Overinflation of alveolar walls c. Roll shoulders forward 2. Easier to penetrate d. SID recommended—72 inches 3. Should not be imaged with use of automatic exposure e. Respiration: Full inspiration (expose at end of sec- controls (AECs) because minimum reaction time of ond inspiration) equipment usually results in overexposure, necessitat- 3. Central ray: Perpendicular to MSP at level of T7 ing repeat exposures (Figure 5-45) L. Empyema B. Lateral 1. Pus in the pleural space 1. Patient position 2. Harder to penetrate a. Standing or seated erect M. Histoplasmosis b. Left side against image receptor unless otherwise 1. Infection caused by inhaling fungal spores specified 2. Harder to penetrate c. Top of image receptor 1 to 2 inches above relaxed N. Hyaline membrane disease shoulder 1. Respiratory distress syndrome of the newborn 2. Part position 2. Acute lung disease in newborn; characteristics include a. MSP parallel to image receptor airless alveoli and rapid respirations b. Adjacent shoulder resting against image receptor 3. Harder to penetrate holder O. Legionnaires’ disease c. Arms raised and crossed over head 1. Form of acute bacterial pneumonia d. Center thorax to image receptor 2. Harder to penetrate e. SID recommended—72 inches P. Pleural effusion f. Respiration: Full inspiration (expose at end of sec- 1. Accumulation of fluid in intrapleural spaces ond inspiration) 2. Harder to penetrate 3. Central ray: Perpendicular to image receptor, entering Q. Pneumoconiosis patient approximately 2 inches anterior to midaxil- 1. Lung disease caused by inhaling dust (usually mineral lary plane at level of T7 (Figure 5-46) dust from the environment or workplace) C. LAO and RAO (PA oblique projections) 2. Silicosis: Caused by prolonged inhalation of silicon 1. Patient position dioxide (sand) a. Standing or seated 3. Anthracosis: Caused by prolonged inhalation of b. Adjust coronal plane 45 degrees (or 60 degrees) anthracite (coal dust) from plane of image receptor 4. Asbestosis: Caused by prolonged inhalation of asbestos c. Top of image receptor 2 inches above shoulders 5. Siderosis: Caused by prolonged inhalation of iron dust d. Side farther from image receptor is usually side of 6. All are harder to penetrate primary interest R. Pneumonia 2. Part position 1. Acute inflammation of the lungs a. Shoulder nearer image receptor rolled posteriorly 2. Harder to penetrate b. Hand placed on hip S. Pneumothorax c. Arm farther from image receptor placed on top of 1. Air in the pleural space that causes the lung to collapse image receptor holder 2. Easier to penetrate d. Thorax centered to image receptor T. Pulmonary metastases e. SID recommended—72 inches 1. Spread of cancer into the lungs from a primary site f. Both 45-degree oblique projections (or 60-degree 2. Harder to penetrate oblique projections) may be taken U. Tuberculosis g. Respiration: Full inspiration 1. Chronic infection of the lungs caused by acid-fast 3. Central ray: Perpendicular at level of T7 bacillus D. AP lordotic 2. More difficult to penetrate 1. Patient position a. Standing approximately 1 foot in front of image Chest receptor A. PA b. When patient is properly positioned, top of image 1. Patient position receptor should be approximately 3 inches above a. Standing or seated erect shoulders 132 PART 1 Review and Study Guide

Air-filled trachea Lung apex 1 4 Clavicle

Scapula 6

Aortic arch 8

Pulmonary 10 markings

Heart

Diaphragm

Right costophrenic angle

Gas in stomach

• Figure 5-45 PA chest.

Collimator

Lung apex Air-filled esophagus Trachea Sternum

Hilar region

Posterior ribs (superimposed)

Heart shadow

Diaphragm

Costophrenic angle

• Figure 5-46 Left lateral chest.

2. Part position e. SID recommended—72 inches a. MSP centered with no rotation f. Respiration: Full inspiration b. Elbows flexed 3. Central ray: Perpendicular to image receptor, entering c. Hands, with palms out, on hips midsternum d. Patient leans backward in extreme lordotic E. Lateral decubitus position 1. Patient position: Lateral recumbent CHAPTER 5 Procedures 133

Left clavicle a. Rotate body 45 degrees with affected side toward Jugular notch image receptor Sternoclavicular b. Center midway between MSP and lateral surface joint of body to center of grid 1st rib c. Abduct arm nearer to image receptor d. Place hand on head Manubrium e. Abduct opposite limb f. Place hand on hip g. Respiration: Above diaphragm, full inspiration; Sternal angle below diaphragm, full expiration 3. Central ray: Perpendicular to image receptor; above diaphragm, center at level of T7; below diaphragm, Body center at level of T10 Sternum A. RAO (PA oblique) 1. Patient position: Prone position for RAO (right PA oblique) 2. Part position a. Center sternum to image receptor b. Rotate body 15 to 20 degrees to prevent superimposition of vertebral and sternal images c. Respiration: Shallow breathing or suspended expi- Xiphoid process ration 3. Central ray: Perpendicular, exiting midsternum • Figure 5-47 RAO of sternum. (Figure 5-47) B. Lateral 1. Patient position: Lateral, seated or standing 2. Part position 2. Part position a. Lying on affected or unaffected side, depending on a. Top of image receptor 1 to 2 inches above jugular existing condition notch b. Elevate dependent side on firm pad b. Shoulders and arms rotated posteriorly c. Extend patient’s arms above head c. Center sternum to image receptor d. Adjust thorax in true lateral position d. Adjust to true lateral position e. Place top of image receptor approximately 2 inches e. Respiration: Full inspiration above shoulders 3. Central ray: Perpendicular to center of midsternum f. Respiration: Full inspiration 3. Central ray: Horizontal and perpendicular to image Sternoclavicular Joints receptor, entering T7 A. PA 1. Patient position: Prone or upright, MSP centered to table Ribs 2. Part position A. AP a. Image receptor centered to T3 1. Patient position: Erect or recumbent b. Arms on side of body, palms up, shoulders in same 2. Part position plane a. Center midsagittal plane to midline of grid c. Bilateral exam: Head rests on chin, MSP vertical to b. Above diaphragm: Center to T7; top of image table receptor should be 1 to 2 inches above shoulders; d. Unilateral exam: Turn head toward affected side, shoulders rotated anteriorly rest cheek on table (1) Respiration: Full inspiration 3. Central ray: Perpendicular to T3 c. Below diaphragm: Center thorax with bottom of B. RAO image receptor at level of iliac crests 1. Patient position: Prone or upright (1) Respiration: Full expiration 2. Part position 3. Central ray: Perpendicular to T7 for upper ribs; per- a. Rotate patient to an oblique position to place ver- pendicular to T12 for lower ribs (bilateral) tebral shadow behind sternoclavicular joint nearer B. LPO and RPO (AP oblique projections) to image receptor (10 to 15 degrees) 1. Patient position: Erect or recumbent b. Center joint to midline of image receptor 2. Part position 3. Central ray: Perpendicular to affected joint 134 PART 1 Review and Study Guide

Frontal sinus

Crista galli

Superior orbital margin

Superior orbital fissure Ethmoidal sinus

Petrous ridge

Inferior orbital margin

• Figure 5-48 PA axial skull (Caldwell method).

Skull b. When sella turcica is of primary interest, image Cranium receptor is centered, and central ray enters ¾ inch A. PA or Caldwell (PA axial) (Figures 5-48 and 5-49) superior and ¾ inch anterior to EAM 1. Patient position: Prone or seated erect C. AP axial (Towne) (Figure 5-51) 2. Part position 1. Patient position: Supine or seated erect a. Head resting on forehead and nose 2. Part position b. MSP perpendicular to midline of grid device a. Center MSP to midline of grid device c. OML perpendicular to image receptor b. Adjust to be perpendicular d. Respiration: Suspended c. Flex head and adjust OML perpendicular to image 3. Central ray receptor a. Caldwell method (PA axial): Direct central ray 15 d. Place top of image receptor at level of cranial vertex degrees caudad to OML, exiting nasion, for survey e. Respiration: Suspended exam 3. Central ray b. PA: Perpendicular to image receptor, exiting a. Direct through foramen magnum with caudal nasion, to examine frontal bone angle of 30 degrees to OML or 37 degrees to B. Lateral (Figure 5-50) IOML, entering 2 to 2½ inches above the glabella 1. Patient position: Seated erect or semiprone D. Submentovertex (full basal) 2. Part position 1. Patient position: Seated erect at head unit or supine on a. Center a point to the image receptor that is 2 inches elevated table support superior to the external auditory meatus (EAM) 2. Part position b. MSP parallel to image receptor a. Extend neck c. IOML parallel to transverse axis of image receptor b. Rest head on vertex d. Interpupillary line (IPL) perpendicular to image c. Center and adjust MSP perpendicular to image receptor receptor e. Respiration: Suspended d. Adjust IOML parallel to plane of image receptor 3. Central ray e. Respiration: Suspended a. Perpendicular, entering 2 inches superior to EAM 3. Central ray: Direct perpendicular to IOML, entering for survey exam between angles of mandible CHAPTER 5 Procedures 135

Frontal sinus

Dorsum sellae

Superior orbital margin

Petrous ridge Ethmoid sinus Inferior orbital margin

Crista galli

• Figure 5-49 PA skull.

Coronal suture

Orbital roof

Sella turcica

Sphenoidal sinus

Petrous portion of temporal bone Temporomandibular joint

External acoustic meatus

Mandibular rami

• Figure 5-50 Lateral skull.

Orbit c. Adjust AML perpendicular to image receptor A. Parietoorbital oblique (Rhese) (Figure 5-52) d. Rotate MSP 53 degrees from image receptor 1. Patient position: Prone or seated erect e. Respiration: Suspended 2. Part position 3. Central ray: Perpendicular, entering 1 inch supe- a. Center affected orbit to image receptor rior and posterior to top of ear attachment, exiting b. Rest head on zygoma, nose, and chin affected orbit 136 PART 1 Review and Study Guide

Parietal bone

Occipital bone

Foramen magnum

Petrous ridge

Posterior clinoid process Dorsum sellae

• Figure 5-51 AP axial skull.

Superior orbital margin

Lateral orbital margin Optic canal and foramen Medial orbital margin

Lesser wing of sphenoid Ethmoidal sinus

Inferior orbital margin

• Figure 5-52 Parietoorbital oblique optic canal (Rhese method).

Facial Bones 2. Part position A. Lateral (Figure 5-53) a. Center and adjust MSP perpendicular to image 1. Patient position: Semiprone or seated erect receptor 2. Part position b. Rest patient’s head on extended chin a. Center zygoma c. Adjust OML to form a 37-degree angle to image b. Adjust MSP parallel to image receptor receptor plane c. IOML parallel to transverse axis of image receptor d. Respiration: Suspended d. IPL perpendicular to image receptor 3. Central ray: Perpendicular, exiting acanthion e. Respiration: Suspended 3. Central ray: Perpendicular, entering lateral surface of Nasal Bones zygomatic bone A. Lateral (performed as bilateral exam) B. Parietoacanthial (Waters) (Figure 5-54) 1. Patient position: Semiprone or seated erect 1. Patient position: Prone or seated erect 2. Part position CHAPTER 5 Procedures 137

Frontal sinus

Nasal bone Sella turcica

Maxillary sinus

External acoustic meatus Maxilla

Mandible

• Figure 5-53 Lateral facial bones.

Orbit

Zygomatic arch Maxillary sinus Maxilla

Mandibular angle

• Figure 5-54 Parietoacanthial facial bones (Waters method).

a. Center nasion to image receptor Zygomatic Arches . b Adjust MSP parallel to image receptor A. Bilateral tangential (basal) . c IOML parallel to transverse axis of image 1. Patient position: Seated erect or supine on elevated receptor table support d. IPL perpendicular to image receptor 2. Part position e. Respiration: Suspended a. Have patient extend head and rest on vertex 3. Central ray: Perpendicular to the bridge of the nose, . b Center and adjust MSP perpendicular to image entering ¾ inch distal to nasion receptor 138 PART 1 Review and Study Guide

c. Adjust IOML parallel to image receptor c. Adjust broad surface of ramus parallel to image d. Respiration: Suspended receptor 3. Central ray: Perpendicular to IOML, entering mid- d. Respiration: Suspended way between zygomatic arches, approximately 1 inch 3. Central ray: Direct 25 degrees cephalad, entering 2 posterior to outer canthi inches distal to the mandibular angle on side farther B. Unilateral tangential (May) from image receptor 1. Patient position: Prone or seated erect at vertical grid D. Submentovertex (basal) device 1. Patient position: Seated erect or supine on elevated 2. Part position table support a. Extend neck and rest chin on grid device 2. Part position b. Rotate MSP 15 degrees away from side being a. Extend neck and rest head on vertex examined; if AP, rotate MSP 15 degrees toward b. Center and adjust MSP perpendicular to image side being examined receptor c. Center image receptor 3 inches distal to most c. Adjust IOML parallel to plane of image receptor prominent point of zygoma d. Respiration: Suspended d. IOML parallel to plane of image receptor 3. Central ray: Perpendicular to IOML, entering mid- e. Respiration: Suspended way between mandibular angles 3. Central ray a. Perpendicular to IOML Temporomandibular Articulations b. Directed through zygomatic arch 1½ inches pos- A. Open-mouth and closed-mouth laterals terior to outer canthus 1. Patient position: Seated erect or semiprone 2. Part position Mandible a. Center a point ½ inch anterior and 1 inch inferior A. PA to EAM to image receptor 1. Patient position: Prone or seated erect b. MSP angled 15 degrees (nose toward image receptor) 2. Part position c. AML adjusted parallel to transverse axis of image a. Have patient rest head on nose and chin receptor b. For mandibular body, center image receptor at d. IPL perpendicular to image receptor level of lips e. After first exposure (made with mouth closed and c. For rami and temporomandibular joint (TMJ), patient completely still), image receptor is changed, center to tip of nose and second exposure is made with patient’s mouth d. MSP perpendicular to image receptor fully open e. Respiration: Suspended f. Respiration: Suspended 3. Central ray 3. Central ray: Direct 15 degrees caudad, exiting TMJ a. For mandibular body, direct perpendicular to against image receptor image receptor at level of lips b. For rami and condylar processes, direct midway Paranasal Sinuses between TMJs at 30-degree cephalad angle A. Lateral (Figure 5-55) B. Axiolateral oblique (for mandibular body) 1. Patient position: Seated erect 1. Patient position: Semiprone or seated erect 2. Part position 2. Part position a. Center image receptor ½ to 1 inch posterior to a. Adjust image receptor under affected cheek outer canthus b. Extend neck to place long axis of mandibular body b. Adjust head to true lateral position parallel to image receptor c. MSP parallel and IPL perpendicular to image c. Center to first molar region receptor d. Adjust broad surface of mandibular body parallel d. IOML adjusted parallel to transverse axis of image to image receptor receptor e. Respiration: Suspended e. Respiration: Suspended 3. Central ray: Direct slightly posteriorly to mandibu- 3. Central ray: Perpendicular, entering ½ to 1 inch pos- lar angle farthest from image receptor at a 25-degree terior to outer canthus cephalad angle B. PA axial (Caldwell) C. Axiolateral oblique (for mandibular ramus) 1. Patient position: Seated erect at vertical grid device 1. Patient position: Semiprone or seated erect 2. Part position 2. Part position a. Rest head on forehead and nose a. Center image receptor ½ inch anterior and 1 inch b. MSP perpendicular to midline of image receptor inferior to affected side EAM c. OML perpendicular to image receptor b. Extend chin d. Respiration: Suspended CHAPTER 5 Procedures 139

3. Central ray: Direct to nasion at angle of 15 degrees 3. Central ray: Horizontal and perpendicular to image caudal to the OML receptor, exiting acanthion C. Parietoacanthial (Waters) D. Submentovertex (basal) (Figure 5-56) 1. Patient position: Seated erect; use horizontal central 1. Patient position: Seated erect at vertical grid device ray to demonstrate fluid level 2. Part position 2. Part position a. Extend head and rest on vertex a. Center and adjust MSP perpendicular to image b. Center and adjust MSP perpendicular to image receptor receptor b. Rest head on extended chin c. Adjust IOML parallel to image receptor c. Adjust OML to form a 37-degree angle to image d. Respiration: Suspended receptor 3. Central ray: Perpendicular to IOML through sella tur- d. Respiration: Suspended cica, approximately ¾ inch anterior to level of EAM

Frontal sinus

Sella turcica

Sphenoidal sinus

Ethmoidal sinuses

Maxillary sinus

Superimposed mandibular rami

• Figure 5-55 Lateral sinuses.

Maxillary sinus

Ethmoidal sinuses

Mandible

Vomer Sphenoidal sinus

Pharynx

Petrosa

• Figure 5-56 Submentovertical sinuses. 140 PART 1 Review and Study Guide

Gastrointestinal System 2. Imaged using barium study 3. Has craterlike appearance Pathologic Conditions Imaged R. Pyloric stenosis: Narrowing of pyloric sphincter A. Acute cholecystitis: Inflammation of gallbladder S. Small bowel obstruction B. Cancer of the colon and rectum 1. Seen as distended loops of bowel that are filled with gas 1. Leading cause of death from cancer in the United 2. Bowel proximal to obstruction may be filled with States fluid 2. More typical form is annular carcinoma, with classic 3. Extent of obstruction determines ease or difficulty of “apple-core” pattern when imaged using a barium penetration enema T. Ulcerative colitis C. Cancer of the esophagus 1. Severe inflammation of the colon and rectum charac- 1. Malignant neoplasm terized by ulceration 2. Imaged during barium study U. Volvulus: Twisting of bowel on itself, causing an obstruction D. Cancer of the stomach 1. May appear as gross changes in the stomach wall or as General Survey Exams a large mass Abdomen 2. Imaged during barium study A. AP (KUB) 3. Harder to penetrate 1. Patient position: Supine E. Cholelithiasis 2. Part position 1. Gallstones a. Center MSP to table 2. Harder to penetrate b. Shoulders in same transverse plane F. Crohn disease c. Support under knees 1. Chronic inflammation of the bowel d. Center image receptor at level of iliac crests 2. Sometimes separated by normal segments of bowel e. Apply gonadal shielding as appropriate G. Diverticulosis f. Respiration: Expiration 1. Presence of diverticula (pouch-like herniations through 3. Central ray: Perpendicular to midline at level of iliac the wall of the colon) crests H. Diverticulitis B. AP (upright) 1. Inflammation of diverticula 1. Patient position: Erect I. Esophageal varices 2. Part position 1. Varicose veins at distal end of esophagus a. Center MSP to table or upright grid device J. Esophagitis b. Shoulders in same transverse plane 1. Inflammation of esophageal mucosal lining c. Center image receptor 2 to 3 inches above iliac K. Gastritis crests to include diaphragm 1. Inflammation of the stomach d. Apply gonadal shielding as appropriate L. Hiatal hernia e. Respiration: Expiration 1. Condition in which a portion of the stomach pro- 3. Central ray: Horizontal, entering MSP 2 to 3 inches trudes through the diaphragm superior to iliac crests M. Ileus C. Lateral decubitus (Figure 5-57) 1. Intestinal obstruction 1. Patient position 2. Adynamic ileus: Ileus caused by immobility of the bowel a. Lateral recumbent (usually left side down), lying 3. Mechanical ileus: Ileus caused by mechanical obstruction on pad N. Intussusception b. Arms above level of diaphragm 1. Prolapse of one segment of bowel into another sec- c. Knees slightly flexed tion of bowel 2. Part position O. Irritable bowel syndrome a. MSP centered to grid device 1. Abnormal increase in small and large bowel motility b. Center image receptor at level of iliac crest P. Large bowel obstruction c. Apply gonadal shielding as appropriate 1. Characterized by massive accumulation of gas proxi- d. Respiration: Expiration mal to obstruction 3. Central ray: Horizontal and parallel to the MSP at 2. Absence of gas distal to obstruction level of iliac crest 3. High risk of bowel perforation 4. Extent of obstruction determines ease or difficulty of Upper Gastrointestinal System penetration Esophagus Q. Peptic ulcer disease A. RAO (PA oblique) 1. Loss of mucous membrane in a portion of the gastro- 1. Patient position: Recumbent with right arm posterior, intestinal (GI) system left arm by head CHAPTER 5 Procedures 141

Air-fluid interface

Diaphragm

Intestinal gas

Surgical clips

Crest of ilium

Patient support

• Figure 5-57 AP abdomen. Left lateral decubitus position resulting in air marked by air-fluid interface.

Fundus

Greater curvature

Duodenal bulb

Pylorus

• Figure 5-58 Single-contrast PA oblique stomach (RAO position).

2. Part position 2. Part position a. Elevate left side to obliquity of 35 to 40 degrees a. Center at level of pylorus (approximately midway b. Support patient on flexed knee and elbow between xiphoid process and umbilicus) c. Align esophagus and center at level of T5 or T6 b. Center halfway between midline and lateral bor- d. Feed barium to patient der of abdominal cavity for 10- × 12-inch image e. Respiration: Suspended receptor or MSP for 14- × 17-inch image receptor 3. Central ray: Perpendicular to image receptor, entering c. Respiration: Expiration level of T5 or T6 3. Central ray: Perpendicular to image receptor at level of pylorus (L2) Stomach B. RAO (PA oblique) (Figure 5-58) A. PA 1. Patient position: Recumbent with right arm posterior, 1. Patient position: Prone left arm by head 142 PART 1 Review and Study Guide

2. Part position a. Elevate left side and support patient to obliquity Left colic of 40 to 70 degrees b. Longitudinal plane midway between vertebrae and anterior surface of elevated side is centered to Descending image receptor colon c. Center at level of duodenal bulb Transverse d. Respiration: Expiration colon 3. Central ray: Perpendicular to center of image receptor Right colic midway between vertebral column and lateral border flexure of abdominal cavity at level of L2 C. Lateral 1. Patient position: Recumbent (right lateral) or erect (left lateral) Ascending 2. Part position colon a. Center image receptor between midaxillary plane and anterior abdominal surface b. Center at level of pylorus Sigmoid c. Adjust to true lateral d. Respiration: Expiration 3. Central ray: Perpendicular to center of image receptor Rectum midway between midaxillary line and anterior surface of abdomen at the level of L1 for recumbent position • Figure 5-59 Double-contrast PA large intestine. or L3 for upright position

Small Bowel Left colic flexure A. PA 1. Patient position: Prone 2. Part position a. MSP centered to table Right colic b. Center image receptor at level of iliac crest (may flexure be slightly higher for early time exposures) c. Respiration: Suspended Descending colon 3. Central ray: Perpendicular to image receptor entering midline at level of iliac crest (or slightly above) Ascending colon Lower Gastrointestinal System Colon Sigmoid A. PA (Figure 5-59) 1. Patient position: Prone 2. Part position a. MSP centered to table b. Center image receptor at level of iliac crest c. Respiration: Suspended 3. Central ray: Perpendicular to image receptor, entering level of iliac crest • Figure 5-60 Double-contrast PA oblique large intestine. B. PA axial 1. Patient position: Prone C. LAO and RAO (PA oblique) (Figure 5-60) 2. Part position 1. Patient position: PA oblique a. MSP centered to table 2. Part position b. Center image receptor at level of iliac crest a. Patient rotated 35 to 45 degrees c. Respiration: Suspended b. Either right or left side up 3. Central ray c. Center abdomen to table a. From 30 to 40 degrees caudad d. Image receptor centered at level of iliac crest b. To show rectosigmoid area using smaller image e. Respiration: Suspended receptor, central ray enters midline at level of 3. Central ray: Perpendicular to image receptor, entering ASIS level of iliac crest CHAPTER 5 Procedures 143

D. Lateral rectum b. Left side of body may be elevated into a 15- to 1. Patient position: Lying on side 20-degree oblique angle to prevent bile ducts from 2. Part position being superimposed over the spine a. Adjust patient’s body to true lateral position (right 3. Central ray: Perpendicular to exposed biliary tract or left side down) 4. Procedure notes b. Center midaxillary plane of abdomen to center of a. Surgeon directs imaging sequence table b. Equipment must be properly cleaned and ready to c. Respiration: Suspended use 3. Central ray: Perpendicular to image receptor, entering c. Radiographer must be in proper operating room midaxillary plane at level of ASIS attire E. AP d. Appropriate radiation protection standards must be 1. Patient position: Supine maintained for the radiographer and for the operat- 2. Part position ing room staff, using distance and lead shielding a. MSP centered to table e. Exposure times must be as short as possible, with b. Image receptor centered at level of iliac crest patient respiration controlled by the anesthetist c. Respiration: Suspended 5. Exam evaluation: Patency of the bile ducts, operation 3. Central ray: Perpendicular to image receptor, entering of the sphincter of the hepatopancreatic ampulla, and level of iliac crest presence of calculi F. AP axial 1. Patient position: Supine Endoscopic Retrograde 2. Part position Cholangiopancreatography (ERCP) a. MSP centered to table A. Endoscopic retrograde cholangiopancreatography (ERCP) b. Image receptor centered 2 inches above iliac exam notes crest 1. Used to evaluate biliary and pancreatic pathologic c. Respiration: Suspended conditions 3. Central ray 2. Endoscope is passed into duodenum under fluoro- a. Cephalad 30 to 40 degrees, entering approxi- scopic control mately 2 inches below level of ASIS 3. Contrast medium is injected into the common bile b. When rectosigmoid is of interest, central ray enters duct or pancreatic duct through a cannula passed inferior margin of symphysis pubis through the endoscope G. Lateral decubitus 4. Patient is placed prone for imaging 1. Patient position: Lying on either right or left side, 5. ERCP may be preceded by ultrasound patient’s MSP centered to midline of grid 2. Part position Urinary System a. Arms above head Pathologic Conditions Imaged b. Knees slightly flexed A. Carcinoma of the bladder c. Image receptor centered to abdomen at level of 1. Seen as solid mass arising from the bladder wall iliac crest 2. Harder to penetrate d. Respiration: Suspended B. Cystitis: Inflammation of bladder and ureters 3. Central ray: Horizontal, entering midline at level of C. Glomerulonephritis: Inflammation of the glomerulus of iliac crest the kidney H. LPO and RPO (AP oblique) D. Polycystic kidney disease 1. Patient position: AP oblique 1. Enlarged kidneys containing numerous cysts 2. Part position 2. Harder to penetrate a. Patient rotated 35 to 45 degrees from AP position; E. Pyelonephritis: Inflammation of renal pelvis and paren- either right or left side up chyma b. Center abdomen to table F. Renal calculus c. Image receptor centered at level of iliac crest 1. Kidney stone d. Respiration: Suspended 2. Harder to penetrate stone, but overall technique is 3. Central ray: Perpendicular to image receptor at level not increased to compensate of iliac crest G. Renal carcinoma 1. Solid mass cancer that causes renal bulging or enlarge- Surgical Cholangiogram ment with impact on collecting system A. AP or AP oblique 2. Harder to penetrate 1. Patient position: Supine on operating table H. Renal cysts 2. Part position 1. Fluid-filled masses in kidney a. Right upper quadrant centered to image receptor 2. Harder to penetrate 144 PART 1 Review and Study Guide

I. Wilms tumor 2. NPO (nothing by mouth) after midnight the day of 1. Malignant cancer of kidney in children the exam but not dehydrated 2. Harder to penetrate 3. Preliminary KUB is performed before contrast agent injection to verify positioning, visualize renal Urinary System Procedures anatomy, or detect the presence of lesions Intravenous Urography 4. Based on patient weight, 30 to 100 mL of iodinated A. KUB (AP) (Figure 5-61) contrast medium is injected; pelvicalyceal system 1. Patient position: Supine, centered to the table appears in 2 to 8 minutes, with greatest visualiza- 2. Part position tion occurring in 15 to 20 minutes a. Spine centered to table 5. AP and oblique images are obtained at specific b. Include entire renal outlines, bladder, and sym- intervals after injection of contrast medium physis pubis; also include prostatic region on older 6. All images must be carefully identified using right, adult male patients left, upright, and “postvoid” markers and numbers 3. Central ray: Perpendicular to image receptor, centered indicating postinjection time at level of iliac crest 7. AP upright positions may be used to show kidney B. Oblique (RPO, LPO) (Figure 5-62) mobility and filled bladder 1. Patient position: Supine 8. Oblique images may be used to image kidney rota- 2. Part position: Patient’s body rotated to a 30-degree tion or localize tumor masses oblique angle; kidney farther from the image receptor 9. Postvoid images may be taken to image tumor is parallel to image receptor, and kidney nearer to the masses or prostatic enlargement image receptor is perpendicular to image receptor 10. Intravenous urography is increasingly being used in 3. Central ray: Perpendicular to image receptor at iliac crest conjunction with, or replaced by, computed tomog- C. AP bladder raphy (CT), eliminating some of above steps 1. Patient position: Supine 2. Part position: Supine, centered to image receptor Cystography and Cystourethrography 3. Central ray: Perpendicular to image receptor, cen- A. Positioning tered at level of ASIS 1. AP axial D. Intravenous pyelogram (IVP) (intravenous urogram) a. Angle 10 to 15 degrees caudal; only 5 degrees cau- procedure notes dal for bladder neck 1. Patient should be properly prepared with a low- b. Image receptor centered at level 2 to 3 inches above residue diet for 1 to 2 days before the exam and symphysis pubis cleansing of GI tract 2. Oblique (RPO, LPO) a. Patient rotated 40 to 60 degrees b. Pubic arch closest to table centered to midline of table

Renal calyces Renal pelvis

Renal pelvis Gas in colon Ureter Abdominal ureter

Pelvic ureter Ureteral compression devices

Urinary bladder

• Figure 5-61 Urogram from supine position at 15-minute interval with gas-filled stomach. • Figure 5-62 AP oblique urogram 10 minutes after injection. CHAPTER 5 Procedures 145

3. PA of bladder to compress cisterna magna when contrast medium is a. Patient centered used in cervical region b. Central ray enters 1 inch distal to tip of coccyx 7. Images are taken under fluoroscopic control in PA with 10- to 15-degree cephalad angle and oblique positions 4. Lateral 8. Cross-table lateral images are taken by radiographer a. Bladder centered to image receptor; image recep- to provide right-angle views tor 2 to 3 inches above symphysis pubis 9. Contrast medium is absorbed by patient’s body b. Central ray centered and perpendicular to image B. Arthrography receptor 1. Contrast exam of an encapsulated joint B. Procedure notes a. Knee 1. Bladder is drained with catheter that has been put in b. Shoulder place c. Hip 2. Bladder is filled with contrast medium through ure- d. Wrist thral catheter e. TMJ 3. After bladder is filled, clamp is closed to prevent con- 2. Pathologic conditions imaged trast agent from draining a. Joint trauma 4. Imaging follows filling of bladder b. Meniscal tears 5. Cystourethrography may follow cystogram c. Capsular damage a. Patient is instructed to void contrast material from d. Deformities caused by arthritis bladder while on fluoroscopic table e. Rupture of articular ligaments b. Radiologist takes spot images during urination to evaluate urethra and to image reflux TABLE Common Additive and Destructive Diseases 5-1 and Conditions by Anatomic Area Retrograde Pyelography A. Positioning Additive Conditions Destructive Conditions 1. AP Abdomen 2. RPO Aortic aneurysm Bowel obstruction 3. LPO B. Procedure notes Ascites Free air 1. Ureters are catheterized to allow filling of the pelvi- Cirrhosis calyceal system Hypertrophy of some organs 2. Urologist performs procedure (e.g., splenomegaly) 3. Image receptor is placed to include both kidneys and ureters Chest 4. After catheterization and introduction of contrast Atelectasis Emphysema material, urologist directs imaging sequence Congestive heart failure Pneumothorax Table 5-1 lists common additive and destructive diseases and conditions. Malignancy Pleural effusion Other Radiologic Exams Pneumonia A. Myelography 1. Pathologic conditions imaged Skeleton a. Herniated intervertebral disks Hydrocephalus Gout b. Degenerative diseases of the CNS Metastases (osteoblastic) Metastases (osteolytic) c. Space-occupying lesions 2. Pathologic changes are imaged by displacement of Osteochondroma (exostoses) Multiple myeloma column of contrast material in the subarachnoid Paget disease Paget disease space Osteoporosis 3. Lumbar puncture performed by physician at L3-4 interspace allows injection of water-soluble contrast Nonspecific sites agent into subarachnoid space Abscess Atrophy 4. Small amount of spinal fluid is withdrawn for labora- Edema Emaciation tory analysis 5. X-ray table is tilted up and down to distribute con- Sclerosis Malnutrition trast medium From Fauber TL: Radiographic imaging and exposure, ed 4, St. Louis, 6. Contrast medium should not be allowed to enter 2012, Mosby. cerebral ventricles; head must be kept hyperextended 146 PART 1 Review and Study Guide

3. Performed under local anesthetic with use of asepsis 4. Preliminary image (AP) centered 2 inches proximal 4. Physician injects contrast material to symphysis pubis 5. Joint is manipulated to distribute contrast agent 5. Physician introduces water-soluble iodinated contrast 6. Fluoroscopic images may be taken agent through cervix and into uterus 7. Arthrography is increasingly being replaced by MRI 6. Fluoroscopic or radiographic images (AP) are taken to C. Hysterosalpingography visualize the uterus and contrast agent flow through 1. Pathologies imaged the fallopian tubes a. Abnormal uterine bleeding 7. Images indicate shape of uterus, presence of patholo- b. Amenorrhea gies, and patency of oviducts c. Cervical stenosis 8. Other images may be taken in LPO or RPO positions d. Dysmenorrhea 9. Contrast agent is absorbed by patient and excreted by e. Fistulae urinary system f. Masses g. Neoplasms KEY REVIEW POINTS h. Patency of oviducts (assessment of possible infer- tility) Review of Radiography Positioning, Procedures, i. Polyps and Pathology j. Uterine anomalies These three topics are collectively tested as part of one 2. Therapeutic procedures category on the certification exam. These topics constitute the a. Dilate oviducts heart of radiographic procedures. Use this review to reinforce b. Open oviducts what you have learned in class and clinical education. Make c. Remove kinks use of the labeled radiographs. Be able to define, in words, 3. Contraindications include pregnancy, pelvic inflam- the pathologic conditions presented. matory disease, uterine bleeding

Review Questions 1. What body type is a slender build? 6. What body type has the stomach and gallbladder high a. Hypersthenic habitus and horizontal? b. Sthenic habitus a. Hypersthenic habitus c. Hyposthenic habitus b. Sthenic habitus d. Asthenic habitus c. Hyposthenic habitus 2. What body type is a massive build? d. Asthenic habitus a. Hypersthenic habitus 7. What body type has the thorax narrow and shallow? b. Sthenic habitus a. Hypersthenic habitus c. Hyposthenic habitus b. Sthenic habitus d. Asthenic habitus c. Hyposthenic habitus 3. What body type has the stomach and gallbladder low, d. Asthenic habitus vertical, and near the midline? 8. What body type has the thorax broad and deep? a. Hypersthenic habitus a. Hypersthenic habitus b. Sthenic habitus b. Sthenic habitus c. Hyposthenic habitus c. Hyposthenic habitus d. Asthenic habitus d. Asthenic habitus 4. What body type is average build, present in about 9. Key points in performing pediatric radiography are: 35% of the population? a. Work quickly and impersonally, use gonadal a. Hypersthenic habitus shielding, report suspected child abuse, keep par- b. Sthenic habitus ents in waiting room c. Hyposthenic habitus b. Work quickly, communicate clearly with child and d. Asthenic habitus parents, use gonadal shielding, report suspected 5. What is the most common body habitus, present in child abuse about 50% of the population? c. Work quickly and impersonally, report suspected a. Hypersthenic habitus child abuse, keep parents in waiting room, always b. Sthenic habitus use Pigg-O-Stat c. Hyposthenic habitus d. Work quickly and impersonally, use gonadal d. Asthenic habitus shielding only on abdominal exams, report suspected child abuse, keep parents in waiting room CHAPTER 5 Procedures 147

10. The most important point to remember when per- 18. What type of joint has a rounded head of one bone forming trauma radiography is: that moves in a cuplike cavity? a. Use gonadal shielding because this patient will be a. Ball-and-socket joint having many follow-up exams b. Pivot joint b. Work quickly because the injuries may be life- c. Hinge joint threatening d. Saddle joint c. Do no additional harm to the patient 19. What type of joint permits motion in one plane only? d. Perform only the projections ordered by the a. Ball-and-socket joint physician b. Pivot joint 11. When you are performing trauma radiography: c. Hinge joint a. Splints, bandages, and cervical collars should be d. Saddle joint removed so that they do not obstruct the anatomy 20. What type of joint has opposing surfaces that are that must be imaged convex-concave, allowing great freedom of motion? b. Remove cervical collars only under the direction a. Ball-and-socket joint of a radiologist b. Pivot joint c. Remove cervical collars only under the direction of c. Hinge joint an emergency department physician or radiologist d. Saddle joint d. Splints, bandages, and cervical collars should be 21. What type of joint permits rotary movement in which removed only after preliminary images have been a ring rotates around a central axis? viewed by a physician so that they do not obstruct a. Ball-and-socket joint the anatomy that must be imaged b. Pivot joint 12. What plane passes transversely across the body? c. Hinge joint a. Transverse plane d. Saddle joint b. Midcoronal plane 22. The minimum two projections needed for every c. Median sagittal plane radiographic exam are: d. Sagittal plane a. Flat and upright 13. What plane passes vertically through the midline of b. Two at right angles to one another the body from front to back? c. AP and lateral a. Transverse plane d. Right and left oblique b. Midcoronal plane 23. Patient respiration when imaging the lower ribs is: c. Median sagittal plane a. Suspended at the end of deep inspiration d. Sagittal plane b. Suspended 14. What plane divides the body into superior and infe- c. Suspended at the end of second inspiration rior portions? d. Suspended at the end of expiration a. Transverse plane 24. Which of the following statements are true regarding b. Midcoronal plane contrast arthrography? c. Median sagittal plane 1. Asepsis is required d. Sagittal plane 2. The exam may be performed on knee, shoulder, 15. What plane passes vertically through the midaxillary TMJ, hip, and wrist region of the body and through the coronal suture of 3. Indications include trauma, capsular damage, the cranium at right angles to the midsagittal plane? meniscal tears, rupture of ligaments, and arthritis a. Transverse plane 4. The joint is manipulated by hand to distribute b. Midcoronal plane contrast medium c. Median sagittal plane a. 1, 2, 3, 4 d. Sagittal plane b. 1, 2 16. What describes any plane parallel to the midsagittal c. 3, 4 plane? d. 2, 3 a. Transverse plane 25. Which of the following statements are true concern- b. Midcoronal plane ing myelography? c. Median sagittal plane 1. Injection is always performed at the L3-4 d. Sagittal plane interspace 17. What type of joint is the hip? 2. Oily, iodinated contrast agent is the medium of a. Ball-and-socket joint choice b. Pivot joint 3. Indications include herniated intervertebral disks, c. Hinge joint space-occupying lesions, and degenerative diseases d. Saddle joint of the CNS 148 PART 1 Review and Study Guide

4. Contrast medium is distributed by manual manip- 3. The humeral epicondyles are placed perpendicular ulation of the subarachnoid space to the image receptor 5. The head must be kept hyperflexed so that the con- 4. The arm should be slightly adducted trast medium does not enter the cerebral ventricles 5. The central ray is directed perpendicular to the 6. Spinal fluid may be withdrawn for laboratory analysis midshaft a. 1, 2, 4 a. 2, 3, 5 b. 2, 4, 5 b. 1, 4 c. 1, 2, 3, 5 c. 2, 4 d. 3, 6 d. 1, 2, 3, 5 26. Intravenous urography is being replaced by which 32. F or a scapular Y projection (PA oblique) of the shoul- imaging modality? der, which of the following statements are true? a. CT 1. The central ray is directed to the shoulder at a b. MRI 10-degree cephalad angle c. Nuclear medicine 2. The anterior surface of the affected shoulder is cen- d. Sonography tered to the image receptor 27. The proper centering point for a PA projection of the 3. The patient is otatedr so that the midcoronal plane hand is the: forms a 45- to 60-degree angle with the image a. Thir d metatarsophalangeal joint receptor b. Thir d metacarpophalangeal joint 4. The patient continues shallow breathing during c. M idshaft of the third metacarpal exposure d. F irst metacarpophalangeal joint a. 1, 2 28. F or a lateral projection of the wrist: b. 2, 3, 4 a. The radius and ulna should be superimposed c. 2, 3 b. The radial surface must be in contact with the d. 1, 2, 3 image receptor 33. F or an AP projection of the AC joints: c. The central ray is parallel a. T o show AC separation properly, joints both with d. U se the fastest image receptor speed possible and without weights should be shown on one 29. F or a lateral projection of the forearm, which of the image receptor if possible following statements are true? b. To show AC separation properly, separate images 1. The ulnar surface must be in contact with the must be acquired with equal weights attached to image receptor both wrists and without weights 2. The thumb should be in a elaxedr position c. The central ray is always directed midway between 3. The humerus and forearm should be in contact the AC joints with the table d. The patient should be seated upright and instructed 4. The elbow should be flexed 45 degrees to continue shallow breathing during the exposure 5. The central ray is directed toward the injured joint 34. When the clavicle is being radiographed, which of the a. All are true following statements are true? b. 1, 2, 5 1. PA projection must always be used c. 1, 3 2. A central ray angle of 25 to 30 degrees cephalad is d. 2, 4, 5 used for the PA axial projection 30. F or an AP projection of the elbow, which of the fol- 3. The patient’s head should be turned away from the lowing statements are true? affected side 1. The forearm and humerus should be at right angles 4. AP projection may be used for patient comfort 2. The central ray is directed perpendicular to the joint 5. An erect position may be used for patient comfort 3. The forearm and humerus should be parallel to the 6. A central ray angle of 25 to 30 degrees caudad is table used for the PA axial projection 4. The hand must be pronated a. 1, 2, 3, 4, 5 5. The patient may have to lean laterally to ensure AP b. 1, 3, 4, 5 alignment c. 2, 3, 4, 5 a. 1, 2 d. 3, 4, 5, 6 b. 2, 3, 5 35. F or the lateral projection of the scapula, which of the c. 1, 4 following statements are true? d. 2, 3, 4, 5 1. Patient should be upright to reduce pain 31. F or a lateral projection of the humerus, which of the 2. Patient is positioned obliquely with unaffected following statements are true? scapula centered to the image receptor 1. The hand should be pronated 3. The bodyis adjusted by palpating axillary and verte- 2. The patient may be upright or supine bral borders of the scapula so that the scapula is lateral CHAPTER 5 Procedures 149

4. Scapula must be projected free of the rib cage b. 2, 4 a. 1, 3, 4 c. 2, 5 b. 2, 3 d. 1, 3, 4, 5 c. 3, 4 43. For a medial oblique position of the ankle, which of d. 2, 3, 4 the following statements are true? 36. What is the name of a fracture of the medial and lat- 1. The leg and foot are rotated medially eral malleoli of the ankle with ankle joint dislocation? 2. The ankle is adjusted to a 90-degree angle a. Trimalleolar fracture 3. The medial rotation is adjusted to 45 degrees to b. Giant cell myeloma show the mortise joint c. Osteoarthritis 4. The medial rotation is adjusted to 15 to 20 degrees d. Pott fracture to show the bony structure 37. What condition involves the posterior portion of the 5. The central ray is directed vertically midway tibia and the medial and lateral malleoli? between the malleoli a. Trimalleolar fracture a. 1, 4 b. Giant cell myeloma b. 1, 5 c. Osteoarthritis c. 1, 3, 4, 5 d. Pott fracture d. 1, 2, 3, 4 38. What condition is more commonly seen in elderly 44. For a lateral lower leg projection, which of the follow- patients? ing statements are true? a. Trimalleolar fracture 1. The leg is centered to the image receptor b. Giant cell myeloma 2. The exam may be performed with the patient on c. Osteoarthritis the tabletop or Bucky d. Pott fracture 3. Roll the patient away from the affected side 39. What is a tumor that arises on bone with a large bub- 4. The patella should be perpendicular to the image ble appearance and may be benign or malignant? receptor a. Trimalleolar fracture 5. Include both joints b. Giant cell myeloma 6. The tibia and fibula should be superimposed c. Osteoarthritis 7. The central ray is directed to the midpoint of the leg d. Pott fracture a. 1, 2, 3 40. What condition is characterized by the degeneration b. 1, 2, 3, 4, 5, 7 of one or several joints? c. 1, 4, 5, 6, 7 a. Trimalleolar fracture d. 1, 2, 4, 5, 7 b. Giant cell myeloma 45. When a lateral knee projection is performed, which of c. Osteoarthritis the following statements are true? d. Pott fracture 1. The patient turns onto the affected side 41. For AP radiography of the foot, which of the follow- 2. The knee is flexed 20 to 30 degrees ing statements are true? 3. The patella must be parallel to the image receptor 1. A wedge-compensating filter may be used 4. The central ray is directed 5 to 7 degrees caudad 2. The dorsal surface rests on the image receptor 5. The central ray enters the knee joint inferior to the 3. The central ray is directed 10 degrees toward the heel medial epicondyle 4. The central ray is directed at the head of the third a. 1, 2, 3 metatarsal b. 1, 2, 3, 5 a. 1, 2, 3, 4 c. 1, 2, 5 b. 1, 3 d. 1, 2, 4, 5 c. 2, 4 46. For a tangential projection of the patella, which of the d. 1, 3, 4 following statements are true? 42. When an AP axial projection is performed for the os 1. The patient is prone calcis, which of the following statements are true? 2. The affected knee is flexed so that the tibia and 1. The leg should be fully extended fibula form a 50- to 60-degree angle with the table 2. The plantar surface of the foot should be parallel to 3. The central ray is directed 45 degrees cephalad the image receptor through the patellofemoral joint 3. The central ray is directed 40 degrees cephalad to 4. The tangential patella projection may also be per- the long axis of the foot formed with the patient supine 4. The central ray enters the foot at the head of the a. 1, 2, 3, 4 fifth metatarsal b. 2, 3, 4 5. A cylinder cone may be used for this projection c. 1, 2, 3 a. 1, 3, 5 d. 1, 2, 4 150 PART 1 Review and Study Guide

47. For an AP projection of the femur: 4. The cervical collar should be removed so that it a. The lower leg should be rotated laterally 15 degrees does not obstruct pertinent anatomy b. The central ray is directed toward the affected 5. The chin should be in contact with the chest joint a. 1, 2, 4 c. The patient is prone b. 1, 2, 3 d. The lower leg is rotated medially 15 degrees c. 1, 2, 3, 5 48. The central ray for an AP projection of the hip is: d. 1, 2, 4, 5 a. Directed parallel to a point 2 inches medial to the 55. For a lateral projection of the thoracic spine, which of ASIS and at the level of the superior margin of the the following statements are true? greater trochanter 1. The head and spine should be in the same plane b. Directed parallel to a point 2 inches lateral to the 2. The central ray is directed to T7, at a cephalad ASIS and at the level of the superior margin of the angle of 10 degrees greater trochanter 3. The patient should continue shallow breathing c. Directed parallel to a point 2 inches medial to the during exposure ASIS and at the level of the inferior margin of the 4. The exam should not be performed in a room with greater trochanter a falling load generator, if possible d. Directed 2.5 inches distal on a line drawn perpen- a. 1, 2 dicular to the midpoint of a line between the sym- b. 1, 3 physis pubis and the ASIS c. 1, 3, 4 49. What condition is commonly caused by motor vehi- d. 1, 2, 3 cle accidents? 56. For a lateral projection of L5-S1, which of the follow- a. Jefferson fracture ing statements are true? b. Hangman fracture 1. The patient is in a lateral position c. Spondylolysis 2. The hips and knees are extended d. Spina bifida 3. The image receptor is centered to the CR 50. What condition is caused by acute hyperextension of 4. A cylinder cone may be used to reduce greatly the the head on the neck and a fracture of the arch of C2? production of scatter radiation a. Jefferson fracture 5. The central ray is centered on a coronal plane 2 b. Hangman fracture inches posterior to the ASIS and 1½ inches infe- c. Spondylolysis rior of the iliac crest d. Spina bifida a. 1, 2, 3, 4, 5 51. What is a defect of the posterior aspect of the spinal b. 1, 2 canal caused by failure of the vertebral arch to form c. 1, 2, 3, 5 properly? d. 1, 3, 4, 5 a. Jefferson fracture 57. For RPO and LPO positions for sacroiliac joints: b. Hangman fracture a. Image the joint nearest the image receptor c. Spondylolysis b. The part must be angled at 10 to 15 degrees to d. Spina bifida coincide with the angle of the joints 52. What is a defect in the pars articularis? c. Image the joint farthest from the image receptor a. Jefferson fracture d. The central ray must be angled 25 degrees b. Hangman fracture cephalad c. Spondylolysis 58. For an AP projection of the coccyx: d. Spina bifida a. The central ray should be directed 10 degrees cau- 53. What is a comminuted fracture of the ring of the atlas dad, entering 2 inches superior to the symphysis that involves both anterior and posterior arches and pubis causing displacement of the fragments? b. The central ray should be directed 10 degrees a. Jefferson fracture cephalad, entering 2 inches superior to the sym- b. Hangman fracture physis pubis c. Spondylolysis c. The central ray should be directed 25 degrees cau- d. Spina bifida dad, entering 2 inches superior to the symphysis 54. For a lateral projection of the cervical spine, which of pubis the following statements are true? d. The central ray should be directed 25 degrees cau- 1. The patient may be upright, seated, or supine, dad, entering 4 inches superior to the symphysis depending on his or her condition pubis 2. SID of 72 inches should be used because of 59. Which pathologic condition is easy to penetrate? increased object-to-image receptor distance a. Atelectasis 3. The shoulders should lie in the same plane b. Bronchogenic carcinoma CHAPTER 5 Procedures 151

c. COPD c. The patient should breathe during exposure; a fall- d. Emphysema ing load generator should be used if possible 60. What condition is a collapse of lung tissue and is d. An AP projection is used to reduce magnification harder to penetrate? of joints a. Atelectasis 68. What condition is characterized by soft bones result- b. Bronchogenic carcinoma ing from deficiency of vitamin D and sunlight? c. COPD a. Hydrocephalus d. Emphysema b. Paget disease 61. What condition is characterized by air trapped in the c. Osteoporosis alveoli, which makes the condition very easy to pen- d. Rickets etrate? 69. What condition is a bone disease that causes bone a. Atelectasis destruction and unorganized bone repair and is gen- b. Bronchogenic carcinoma erally difficult to penetrate? c. COPD a. Hydrocephalus d. Emphysema b. Paget disease 62. What condition should not be imaged with use of an c. Osteoporosis AEC? d. Rickets a. Atelectasis 70. What condition is an abnormal demineralization of b. Bronchogenic carcinoma bone, seen more often in females? c. COPD a. Hydrocephalus d. Emphysema b. Paget disease 63. What is lung cancer arising from bronchial mucosa? c. Osteoporosis a. Atelectasis d. Rickets b. Bronchogenic carcinoma 71. What condition is marked by abnormal accumula- c. COPD tion of cerebrospinal fluid in the brain? d. Emphysema a. Hydrocephalus 64. What progressive condition is marked by diminished b. Paget disease capabilities of inspiration and expiration? c. Osteoporosis a. Atelectasis d. Rickets b. Bronchogenic carcinoma 72. What condition is most often seen in elderly patients? c. COPD a. Hydrocephalus d. Emphysema b. Paget disease 65. For an AP projection of the ribs above the diaphragm, c. Osteoporosis which of the following statements is true? d. Rickets 1. The top of the image receptor is placed 1 to 2 73. For a direct PA projection of the skull, the central ray inches above the shoulders is directed: 2. The shoulders are relaxed, and the scapulae are flat a. 15 degrees caudad against the table b. 25 degrees caudad 3. The central ray is directed to T7 c. Perpendicular to the image receptor 4. Exposure is performed on full expiration to depress d. Perpendicular to the image receptor, exiting the the diaphragm nasion when the OML is perpendicular to the IR a. 1, 3 74. When the skull is radiographed in the lateral position: b. 1, 2, 3, 4 a. The MSP must be perpendicular to the IR, the c. 1, 2, 3 IOML must be parallel to the IR, and the IPL d. 1, 3, 4 must be parallel to the IR 66. For RAO position of the sternum: b. The MSP and IOML are parallel to the IR, and a. The body should be rotated 45 to 60 degrees to the IPL is perpendicular to the IR prevent superimposition of the sternum and spine c. The MSP is perpendicular to the IR, and the IPL b. The patient is supine is parallel to the IR c. Breathing should be shallow during exposure; a fall- d. The MSP and IOML are perpendicular to the IR, ing load generator should not be used, if possible and the IPL is parallel to the IR d. The best image is obtained with suspended 75. Most radiographic imaging of the skull has been breathing replaced by what imaging modality? 67. For radiography of the sternoclavicular articulations: a. Magnetic resonance imaging a. PA and lateral projections are required b. Nuclear medicine b. RAO or LAO positions are used to eliminate c. Angiography superimposition of joints onto vertebral shadow d. Computed tomography 152 PART 1 Review and Study Guide

76. When a parietoacanthial (Waters) projection is per- 80. What is a condition in which a portion of the stom- formed for the facial bones: ach protrudes through the diaphragm? a. The MSP is parallel to the IR a. Annular carcinoma b. The MSP is perpendicular to the IR, the head b. Crohn disease rests on the chin, and the OML forms a 53-degree c. Hiatal hernia angle with the plane of the image receptor d. Ileus c. The MSP is perpendicular to the IR, the head 81. What condition involves an intestinal obstruction? rests on the chin, and the OML forms a 37-degree a. Annular carcinoma angle with the plane of the image receptor b. Crohn disease d. The MSP is perpendicular to the image receptor c. Hiatal hernia (IR), the head rests on the nose, and the OML d. Ileus forms a 37-degree angle with the plane of the IR 82. What condition involves chronic inflammation of 77. For a unilateral tangential (May) projection of the portions of the bowel? zygomatic arches: a. Annular carcinoma a. The IOML is parallel to the plane of the image b. Crohn disease receptor, the MSP is rotated 15 degrees away from c. Hiatal hernia the affected side, the IR is centered 3 inches dis- d. Ileus tal to the most prominent point of the zygoma, 83. What condition may be adynamic or mechanical? and the central ray is directed perpendicular to the a. Annular carcinoma IOML through the zygomatic arch 1½ inches pos- b. Crohn disease terior to the outer canthus c. Hiatal hernia b. The IOML is parallel to the plane of the image d. Ileus receptor, the MSP is rotated 15 degrees toward the 84. What condition appears in an “apple-core” pattern on affected side, the IR is centered 3 inches distal to a barium enema exam? the most prominent point of the zygoma, and the a. Annular carcinoma central ray is directed perpendicular to the IOML b. Crohn disease through the zygomatic arch 1½ inches posterior to c. Hiatal hernia the outer canthus d. Ileus c. The IOML is parallel to the plane of the image 85. What condition is visualized by performing an upper receptor, the MSP is rotated 15 degrees away from GI series? the affected side, the IR is centered 3 inches distal a. Diverticula to the most prominent point of the zygoma, and b. Ulcerative colitis the central ray is directed perpendicular to the zygo- c. Pyloric stenosis matic arch 1½ inches posterior to the outer canthus d. Adynamic ileus d. The IOML is parallel to the plane of the image 86. What describes a bowel obstruction caused by immo- receptor, the MSP is rotated 25 degrees away from bility of the bowel? the affected side, the IR is centered 3 inches dis- a. Diverticula tal to the most prominent point of the zygoma, b. Ulcerative colitis and the central ray is directed perpendicular to the c. Pyloric stenosis IOML through the zygomatic arch 1½ inches pos- d. Adynamic ileus terior to the outer canthus 87. What condition is characterized by pouch-like her- 78. When the mandibular body is radiographed with the niations of the colonic wall? patient in the SMV position: a. Diverticula a. The head and neck are extended and resting on the b. Ulcerative colitis chin c. Pyloric stenosis b. The MSP is parallel with the IR. d. Adynamic ileus c. The IOML is perpendicular with the plane of the 88. What condition causes a narrowing of the sphincter image receptor, the head and neck are resting on at the distal end of the stomach? the vertex, and the MSP is perpendicular to the IR a. Diverticula d. The IOML is parallel with the plane of the image b. Ulcerative colitis receptor, the head is resting on the vertex, and the c. Pyloric stenosis MSP is perpendicular to the IR d. Adynamic ileus 79. The best survey study of the paranasal sinuses is 89. What condition is a severe inflammation of the colon obtained by use of what projection? and rectum with loss of mucosal lining? a. Lateral a. Diverticula b. Parietoacanthial (Waters) b. Ulcerative colitis c. Upright lateral c. Pyloric stenosis d. SMV d. Adynamic ileus CHAPTER 5 Procedures 153

90. For RAO position of the esophagus: 95. What condition is characterized by fluid-filled masses a. The patient is rotated obliquely by elevation of the in the kidney? right side 35 to 40 degrees, and the esophagus is cen- a. Polycystic kidney disease tered to the image receptor at the level of T5 or T6 b. Renal calculus b. The patient is rotated obliquely by elevation of the c. Wilms tumor left side 35 to 40 degrees, and the esophagus is d. Renal cysts centered at the level of T5 or T6 96. Which of the following is a malignant cancer of the c. The patient is rotated obliquely by elevation of the kidney? right side 55 to 60 degrees, and the esophagus is cen- a. Polycystic kidney disease tered to the image receptor at the level of T5 or T6 b. Renal calculus d. The patient is rotated obliquely by elevation of the c. Wilms tumor left side 55 to 60 degrees, and the esophagus is cen- d. Renal cysts tered to the image receptor at the level of T5 or T6 97. What condition includes enlarged kidneys containing 91. For a PA projection of the stomach: numerous cysts? a. Center midway between the xiphoid process and a. Polycystic kidney disease the umbilicus b. Renal calculus b. Center halfway between the midline and lateral c. Wilms tumor border of the abdominal cavity d. Renal cysts c. Center midway between the manubrium and the 98. Which of the following conditions is seen primarily umbilicus and halfway between the midline and in children? lateral border of abdominal cavity a. Polycystic kidney disease d. Center midway between the xiphoid process and b. Renal calculus the umbilicus and halfway between the midline c. Wilms tumor and lateral border of the abdominal cavity d. Renal cysts 92. For the LPO or RPO positions for the colon: 99. Which of the following describes a kidney stone? a. The patient is prone, rotated 35 to 45 degrees, a. Polycystic kidney disease with the central ray at the level of the iliac crest b. Renal calculus b. The patient is supine, rotated 55 to 60 degrees, c. Wilms tumor with the central ray at the level of ASIS d. Renal cysts c. The patient is supine, rotated 35 to 45 degrees from 100. For RPO and LPO positions of the kidneys: AP, with the central ray at the level of the iliac crest a. The patient is prone, the body is rotated obliquely d. The patient is prone, rotated 55 to 60 degrees, 30 degrees, the kidney farther from the image with the central ray at the level of the iliac crest receptor is imaged in profile, the kidney nearer the 93. For a lateral decubitus position of the colon: image receptor is imaged in its entirety, and the a. The patient is lying on one side, the image receptor central ray is perpendicular to the IR is centered to the iliac crest, and the central ray is b. The patient is supine, the body is rotated obliquely horizontal to the midline at the level of the iliac crest 45 degrees, the kidney farther from the image b. The patient is prone, the image receptor is cen- receptor is imaged in profile, the kidney nearer the tered to the iliac crest, and the central ray is hori- image receptor is imaged in its entirety, and the zontal to the midline at the level of the iliac crest central ray is perpendicular to the IR c. The patient is lying on one side, the image receptor c. The patient is supine, the body is rotated obliquely is centered 3 inches above the iliac crest, and the 30 degrees, the kidney farther from the image central ray is horizontal 3 inches above the iliac crest receptor is imaged parallel to the image receptor, d. The patient is prone, the image receptor is cen- the kidney nearer the image receptor is imaged tered to L1, and the central ray is horizontal to L1 perpendicular to the image receptor, and the cen- 94. A procedure used to evaluate biliary and pancreatic tral ray is perpendicular to the IR pathologic conditions with an endoscope is: d. The patient is supine, the body is rotated obliquely a. Ultrasound 30 degrees, the kidney nearer the image receptor b. MRI is imaged in profile, the kidney farther from the c. ERCP image receptor is imaged in its entirety, and the d. IVP central ray is perpendicular to the IR 6 Challenge Tests

he review tests in this chapter are constructed using a. Compton the same proportion of questions contained on the b. Coherent radiography certification exam. The computer-based c. Photoelectric Tcertification exam asks you questions at random; however, d. Pair production these printed tests are sorted by category. 3. Which photon-tissue interaction produces radiation After you complete your review work and take these that may expose others in the room during fluoros- challenge tests, you are ready to move on to the online ques- copy? tions. There you will find hundreds of additional questions a. Compton presented randomly in 200-question blocks, sectioned to b. Coherent simulate the actual American Registry of Radiologic Tech- c. Photoelectric nologists (ARRT) examination. The online questions are d. Pair production your best practice and preparation. You will be answering 4. The unit of radiation absorbed in air is the: questions on a computer at random, just as you will when a. Sv you take the ARRT exam. There are enough questions to b. Gy a give you many different exams with countless combinations c. Bq of questions, always according to ARRT test specifications. d. Gy t By drilling yourself using this test bank, you will be as pre- 5. The unit of radioactivity is the: pared as possible for test day. a. Becquerel b. Grayt Challenge Test Number 1 c. Sievert d. Graya ARRT Exam Categories: Safety, 6. The unit of effective dose is the: Image Production, Procedures, a. Becquerel Patient Care b. Grayt c. Sievert Read each question and the answer choices carefully. d. Graya Choose the best, most complete answer for each item. Use 7. Linear energy transfer: the results of this test to assess your strengths and weak- a. Is the same for all types of radiation nesses. Do not look up any of the answers until you have b. Is the same for wave and particulate radiations completed the entire test. Correct the test using the answer used in diagnosis and treatment key in the back of the book. Then compute your scores c. Occurs only during x-ray procedures using Table 6-1 to see where you are strong and where you d. Varies for different types of radiation need additional review. Refer to the appropriate chapter in 8. The unit of Bq would be used in what imaging this book for review of the questions you miss. modality? a. Radiography Safety (Questions 1-53) b. CT 1. Attenuation: c. MRI a. Is radiation that emerges from the patient d. Nuclear medicine b. Describes changes in the x-ray beam as it travels 9. Graphs that show the relationship between radiation through the patient received and the organism’s response are called: c. Produces only scatter radiation a. Response curves d. Occurs only at doses used in radiation therapy b. Exposure curves 2. Which photon-tissue interaction makes radiography c. Dose-response curves possible because of its creation of contrast? d. Radiation-threshold curves

154 CHAPTER 6 Challenge Tests 155

10. Medical x-rays are an example of: 19. The use of gonadal shielding on female patients may a. Natural background radiation reduce gonad dose by: b. Artificially produced radiation a. 50% c. Nonionizing radiation b. 75% d. Ionizing, natural background radiation c. 85% 11. Cataractogenesis does not occur at low levels of radia- d. 95% tion exposure; it is best expressed by which of the fol- 20. Cells that are oxygenated are more susceptible to radi- lowing dose-response relationships? ation damage; this describes: a. Threshold a. Target theory b. Nonthreshold b. Direct effect c. Low dose c. Doubling dose d. Occupational dose d. Oxygen enhancement ratio 12. Increased dose equals increased probability of effects 21. The blood count is depressed after a whole-body dose best describes which of the following? equivalent of at least how many rads? a. Stochastic effects a. 10 Sv b. Deterministic effects b. 0.25 Sv c. Direct effect c. 5 Sv d. Indirect effect d. 0.01 Sv 13. The cumulative occupational exposure for a 22-year- 22. Highly reactive ions that have unpaired electrons in old radiographer is: the outer shell are called: a. 220 mSv a. Electrified b. 22 mSv b. Radiolytic c. 11 mSv c. Hydrogen peroxide d. 110 mSv d. Free radicals 14. The annual effective dose limit for the general public, 23. The master molecule that directs cell activities is: assuming frequent exposure, is: a. RNA a. 0.5 mSv b. Hydrogen peroxide b. 500 mSv c. A free radical c. 0.05 mSv d. DNA d. 1.0 mSv 24. The process of somatic cell division is called: 15. The secondary protective barrier used in room shield- a. Mitosis ing must be at least how thick? b. Spermatogenesis 1 a. ⁄32-inch Al equivalent c. Organogenesis 1 b. ⁄16-inch Al equivalent d. Cytogenesis 1 c. ⁄16-inch Pb equivalent 25. The most common effect from exposure to ionizing 1 d. ⁄32-inch Pb equivalent radiation is: 1 16. The intensity of the scattered beam is ⁄1000 the a. Mutations intensity of the primary beam at a ______angle b. Ionization of atoms in the cells 1 m from the patient. c. Cell death a. 45-degree d. Nothing b. 25-degree 26. Most radiation-induced damage to cells occurs: c. 90-degree a. At diagnostic levels of radiation d. 10-degree b. During fluoroscopy 17. If the air kerma measured 6 feet from the x-ray table is c. At doses of radiation much higher than doses used 5 Graya, what is the air kerma measured at a distance in radiography of 3 feet? d. From background radiation a. 20 Graya 27. Radiation doses up to ______are considered rela- b. 10 Graya tively low risk to the embryo and fetus. c. 1.25 Graya a. 5 mSv d. 2.5 Graya b. 10 mSv 18. The minimum source-to-skin distance for fixed fluo- c. 0.01 mSv roscopes is: d. 0.20 mSv a. 15 inches 28. A concept of radiologic practice that encourages radia- b. 12 inches tion users to adopt measures that keep the dose to the c. 10 inches patient and themselves at minimum levels is called: d. 18 inches a. LET b. RBE 156 PART 1 Review and Study Guide

c. MPD c. 50% d. ALARA d. 35% 29. Which of the following is (are) relatively insensitive to 39. The annual effective dose per person from natural radiation? background radiation is approximately: a. Nerve tissue a. 1.0 mSv b. Reproductive cells b. 3.0 mSv c. Epithelial tissue c. 50 mSv d. Immature sperm cells d. 9.0 mSv 30. Somatic effects of radiation: 40. The greatest source of natural background radiation a. Are common to humans is: b. Are caused when a large dose of high-LET radia- a. X-rays tion is received by a large area of the body b. Delta rays c. Are caused after exposure of DNA c. Radon d. Include genetic mutations d. Radium 31. The best way to keep the radiation dose to the patient 41. According to NCRP Report #160, the increase in total low is: exposure is primarily attributed to increased use of: a. Distance a. MRI b. Shielding b. Diagnostic medical ultrasound c. Time c. Fluoroscopy and interventional procedures d. Avoidance of repeat exposures d. CT 32. X-rays may remove electrons from atoms in the body 42. What barrier must be at least 1/16-inch lead equiva- by a process called: lent? a. Electrification a. Lead apron b. Exposure b. Primary protective barrier c. Ionization c. Bucky slot cover d. Radicalizing d. Secondary protective barrier 33. Ionization may cause: 43. CT accounts for approximately what percent dose to a. Stable atoms the population (NCRP Report #160)? b. Production of high-energy x-rays a. 24% c. Formation of new molecules beneficial to the cell b. 50% d. Unstable atoms c. 15% 34. Cell damage may be exhibited as: d. 80% a. Loss of function or abnormal function 44. Meiosis describes the process of division of what type b. Nothing of cells? c. Enhanced function a. Somatic 35. Damage to the cell being irradiated is called: b. Cancer a. Genetic c. Muscle b. Exposed cell d. Germ c. Somatic 45. What is the most important reason for collimating d. Molecular and using gonadal shielding? 36. Radiation effects that show up in the next generation a. To prevent mutations from occurring in the are called: human population a. Genetic b. To prevent ionization of water molecules in the b. Exposed cell body c. Somatic c. To control somatic effects of ionizing radiation d. Molecular exposure 37. Radiation that is contained in the environment is d. To increase contrast in the radiographic image called: 46. What refers to the lifetime accumulated occupational a. Man-made dose? b. Artificial a. Annual accumulated effective dose c. Natural background b. Cumulative effective dose d. Artificial background c. Common effective dose 38. Background radiation is the source of approximately d. Common medical effective dose what percent of human exposure? 47. Exposure times longer than ____ minutes can lead to a. 95% skin effects. b. 82% a. 5 b. 10 CHAPTER 6 Challenge Tests 157

c. 20 57. The height of a sine wave is called: d. 30 a. Wavelength 48. What provides an approximate skin dose where the b. Altitude x-ray beam is entering the patient? c. Amplitude a. Sievert d. Frequency b. Becquerel 58. The transformer that operates on the principle of self- c. Air kerma induction is the: d. Effective dose a. Step-up transformer 49. Two of the following are sources of exposure to natu- b. Step-down transformer ral background radiation. Choose both. c. Induction transformer a. Medical x-rays d. Autotransformer b. Radon 59. Electronic timers used in x-ray equipment allow for c. Certain consumer products exposure times of: 1 d. Microwave ovens a. ⁄100 second 1 e. Dental x-rays b. ⁄1000 second f. Exposure during air travel c. 1 μs 50. The preferred term for radiation exposure is: d. There is no limit to how short the exposure can be a. Coulombs per kilogram 60. To ensure consistency of radiographic quality from b. Gray one exposure to the next, what device may be used? c. Sievert a. Electronic timer d. Air kerma b. Automatic collimation 51. Effective dose limits may be found in what published c. Automatic exposure control material? d. Falling load generator a. Dose limit reports 61. An x-ray machine that uses a continually decreasing b. NCRP reports mA for the shortest times possible uses a(n): c. Environment Protection Agency reports a. Ionization chamber d. Health and Human Services reports b. Phototimer 52. Photon-cell interactions occur: c. AEC a. Predictably d. Falling load generator b. By chance 62. Devices in the x-ray circuit that operate on the prin- c. Seldom ciple of mutual induction are called: d. Only at high radiation doses a. Rectifiers 53. Calipers are used to measure: b. Generators a. Radiation dose c. Timers b. Patient part thickness d. Transformers c. Patient BMI 63. The high-voltage section of the x-ray circuit makes d. Patient body thickness use of what type of transformer? a. Step-up Image Production (Questions 54-103) b. Autotransformer 54. The smallest particle of an element that retains the c. Step-down characteristics of the element is a(n): d. Falling load a. Element 64. The device in the x-ray circuit that changes AC to DC b. Atom is the: c. Molecule a. Autotransformer d. Neutron b. Step-up transformer 55. Atomic mass refers to: c. Rectifier a. The number of protons plus the number of neu- d. Falling load generator trons 65. What type of current is required for proper operation b. The number of electrons of the x-ray tube? c. The number of electron shells a. Direct d. The number of protons b. Falling load 56. X-rays travel as bundles of energy called: c. Alternating a. Protons d. Fluctuating b. Phasers 66. The result of thermionic emission is a(n): c. Particles a. Recoil electron d. Photons b. Electron cloud 158 PART 1 Review and Study Guide

c. Scattered photon 76. Radiographic contrast in computed radiography may d. Characteristic photon be adjusted by changing the: 67. The focusing cup is located at the: a. Window level a. Cathode b. Window width b. Anode c. Area of the patient being irradiated c. X-ray tube window d. Imaging plate d. Control panel 77. The amount of receptor exposure is controlled pri- 68. An interaction that produces x-rays at the anode as marily by: a result of outer shell electrons filling holes in the a. kVp K-shell is called: b. Focal spot size a. Characteristic c. AEC b. Photoelectric d. mAs c. Compton 78. The visible image may also be called the: d. Brems a. Manifest image 69. In digital fluoroscopy, the image should be viewed on b. Image-in-waiting what device to take advantage of the digital capabilities? c. Preprocessed image a. Digital viewbox d. Latent image b. High-resolution monitor 79. The quantity of x-rays produced is directly controlled by: c. High-definition TV a. kVp d. Plasma TV b. OID 70. A primary advantage of digital fluoroscopy is: c. SID a. Postprocessing manipulation of the image d. mAs b. No radiation dose to the patient 80. The rule or law that governs changing technique c. No fluoroscopist required using kVp is the: d. Lower cost a. Inverse square law 71. In digital fluoroscopy and computed radiography, the b. Density maintenance law energy must be changed to digital form by a(n): c. Reciprocity law a. Digital-to-analog converter d. 15% rule b. Flux capacitor 81. If SID is halved, what may be said about receptor c. Analog-to-digital converter exposure? d. DVD-ROM a. Receptor exposure doubles 72. An algorithm is: b. Receptor exposure is reduced by half a. A mathematical hypothesis used in imaging c. Receptor exposure is reduced by one-half of the b. A mathematical formula used to reconstruct the mAs image in digital imaging d. Receptor exposure is quadrupled c. An advanced imaging procedure 82. Distortion that affects the size of the object as repre- d. The mathematical basis for film-screen imaging sented on the radiographic image is called: 73. In computed radiography, each pixel corresponds to a. Minification a shade of gray representing an area in the patient b. Foreshortening known as a(n): c. Elongation a. Pathology d. Magnification b. Density 83. Shape distortion may take the form of: c. Voxel a. Magnification and minification d. Artifact b. Size and shape distortion 74. Lightness and darkness of the image in computed c. Elongation and foreshortening radiography may be adjusted by: d. Magnification and elongation a. Doubling the kVp 84. A longer than usual OID may cause: b. Adjusting the window level a. Elongation c. Adjusting the window width b. Foreshortening d. Using digital fluoroscopy c. Minification 75. The window level in computed radiography is the: d. Magnification a. Area of the patient being irradiated 85. CR cassettes should be erased at least: b. Amount of radiation needed to obtain the a. Every 24 hours image b. Every 48 hours c. Midpoint of densities c. Every 3 months d. Top of the midpoint of densities d. Weekly CHAPTER 6 Challenge Tests 159

86. The equation H/D describes: 96. Consistency of image appearance is achieved through a. Grid radius the use of: b. Contrast a. Higher speed class c. Grid ratio b. Uniform processing codes d. Reciprocity law c. More effective postprocessing 87. If the exposure field is not accurately recognized, the d. Lower exposure index numbers histogram: 97. Which of the following sets of exposure factors would a. Narrows produce an image with the poorest spatial resolution? b. Widens a. 60 mAs, 80 kVp, 40-inch SID, 4-inch OID c. Remains the same b. 30 mAs, 92 kVp, 40-inch SID, 4-inch OID 88. Noise increases with an increase in: c. 120 mAs, 92 kVp, 20-inch SID, 4-inch OID a. mAs d. 15 mAs, 100 kVp, 40-inch SID, 4-inch OID b. Speed class 98. Which of the following sets of exposure factors would c. SID produce an image with the best spatial resolution? d. OID a. 60 mAs, 80 kVp, 72-inch SID, 4-inch OID 89. Edge enhancement provides: b. 30 mAs, 92 kVp, 40-inch SID, 4-inch OID a. Artificial increase in display contrast at an edge of c. 120 mAs, 92 kVp, 20-inch SID, 4-inch OID the image d. 15 mAs, 100 kVp, 40-inch SID, 4-inch OID b. Artificial increase in display brightness at an edge 99. Beam restriction has the following effect on contrast: of the image a. Decreases contrast c. Artificial increase in spatial resolution at an edge of b. Longer scale of contrast the image c. Shorter scale of contrast 90. Which of the following grid errors would result in d. No effect on contrast an image that shows normal exposure in the middle 100. As kVp increases, there is an increased production of: but decreased exposure on the sides and may follow a. Long wavelengths removal and replacement of the grid? b. Low-energy waves a. Upside down c. Short wavelengths b. Off-level d. Electrons c. Lateral decentering 101. The relationship between kVp and receptor exposure is: d. Grid-focus decentering a. Indirect 91. Grid frequency is described as the: b. Directly proportional a. Height of the lead strips divided by the distance c. Direct, although not proportional between the lead strips d. Inverse b. Distance between the lead strips divided by the 102. Grids that have strips angled to coincide with diver- height of the lead strips gence of the x-ray beam are called: c. Number of lead strips per inch or centimeter a. Parallel d. SID at which the grid may be used b. Crosshatch 92. When working with CR and DR, one must be aware c. Focused that their response to scatter radiation is: d. Rhombic a. Very sensitive 103. In digital imaging, the radiographer must be aware that: b. Minimally sensitive a. mAs is the primary controlling factor c. Irrelevant b. The image is determined by the total exposure 93. The images on radiologists’ monitors appear: c. Speed class is the primary controlling factor a. The same as on radiographers’ monitors d. kVp is the primary controlling factor b. In greater detail than on radiographers’ monitors c. In less detail than on radiographers’ monitors 94. A histogram analysis error may be caused by: a. Excessive mAs b. Pixel unresponsiveness c. Inappropriate collimation d. Excessive kVp 95. Smoothing provides: a. Higher spatial resolution b. Equalization c. Evenness in brightness d. Higher contrast resolution 160 PART 1 Review and Study Guide

Procedures (Questions 104-167) Using Figure 6-2, identify the radiographic anatomy of the Using Figure 6-1, identify the radiographic anatomy of the colon. urinary system. e

A d c B

E E b f

h g

• Figure 6-2 AP projection, barium enema (double-contrast enema). F G

107. Structure b is the: a. Transverse colon b. Ascending colon c. Hepatic flexure • Figure 6-1 Retrograde pyelogram. d. Descending colon 108. Structure c is the: a. Transverse colon b. Ascending colon 104. Structure A is the: c. Hepatic flexure a. Renal pelvis d. Splenic flexure b. Ureter 109 Structure d is the: c. Minor calyces a. Transverse colon d. Major calyces b. Splenic flexure 105. Structure B is the: c. Hepatic flexure a. Renal pelvis d. Descending colon b. Urethra 110. Structure f is the: c. Minor calyces a. Jejunum d. Major calyces b. Ascending colon 106. Structure C is the: c. Hepatic flexure a. Renal pelvis d. Descending colon b. Ureter c. Urethra d. Renal pyramids CHAPTER 6 Challenge Tests 161

Using Figure 6-3, identify the radiographic anatomy visual- Using Figure 6-4, identify the anatomy of a lumbar vertebra. ized during an upper GI series.

A L

F E D G J

H I

• Figure 6-4 Lumbar vertebra (superoinferior projection).

115. Structure A is the: a. Pedicle b. Spinous process • Figure 6-3 PA projection of the stomach. c. Transverse process d. Lamina 116. Structure B is the: 111. Structure D is the: a. Pedicle a. Rugae b. Spinous process b. Haustra c. Coracoid process c. Pylorus d. Lamina d. Incisura angularis 117. Structure C is the: 112. Structure E is the: a. Pedicle a. Rugae b. Coronoid process b. Fundus c. Transverse process c. Pylorus d. Lamina d. Cardiac sphincter 118. Structure F is the: 113. Structure K is the: a. Pedicle a. Rugae b. Spinous process b. Haustra c. Transverse process c. Pylorus d. Lumbar angle d. Incisura angularis 114. Structure L is the: a. Rugae b. Fundus c. Pylorus d. Incisura angularis 162 PART 1 Review and Study Guide

Using Figure 6-5, identify the radiographic anatomy of the 121. Structure E is the: cervical spine. a. Acetabulum b. Ischial tuberosity c. Greater trochanter d. Lesser trochanter 122. Structure F is the: a. Obturator foramen b. Ischial tuberosity A c. Greater trochanter d. Lesser trochanter 123. Structure G is the: a. Acetabulum b. Ischial tuberosity B c. Greater trochanter d. Lesser trochanter Using Figure 6-7, identify the radiographic anatomy of the C knee. D

• Figure 6-5 Oblique cervical spine. H

B 119. Structure B is the: C a. Intervertebral foramen b. Spinous process c. Pedicle G A d. Lamina D 120. E Structure C is the: F a. Intervertebral foramen b. Spinous process c. Pedicle d. Lamina Using Figure 6-6, identify the radiographic anatomy of the • Figure 6-7 AP knee. hip.

124. Structure B is the: a. Medial condyle b. A B C Lateral epicondyle c. Lateral condyle d. Lateral plateau 125. Structure D is the: a. Medial condyle b. Lateral epicondyle c. Lateral condyle D d. Tibial plateau E 126. Structure E is the: a. Tibial condyle F b. Lateral epicondyle G c. Lateral condyle d. Tibial plateau 127. Structure G is the: • Figure 6-6 Lateral hip, inferosuperior projection. a. Medial condyle b. Lateral epicondyle c. Lateral condyle d. Tibial plateau CHAPTER 6 Challenge Tests 163

Using Figure 6-8, identify the radiographic anatomy of the Using Figure 6-9, identify the radiographic anatomy of the hand. wrist.

L 2 3 1 4 K 5 M J F E I G H

N O D H A F C B

P E • Figure 6-9 PA wrist.

D Q 132. Structure A is the: a. Pisiform C b. Hamate c. Triquetral B R d. Scaphoid 133. Structure B is the: a. Hamate b. Lunate A c. Triquetral d. Scaphoid • Figure 6-8 PA radiograph of right hand. 134. Structure C is the: a. Pisiform b. Lunate 128. Structure A is the: c. Triquetral a. First proximal interphalangeal joint d. Trapezium b. First carpometacarpal joint 135. Structure D is the: c. Second distal interphalangeal joint a. Pisiform d. Second metacarpophalangeal joint b. Lunate 129. Structure G is the: c. Triquetral a. Second proximal interphalangeal joint d. Hamate b. First carpometacarpal joint 136. Structure E is the: c. Second distal interphalangeal joint a. Hamate d. Second metacarpophalangeal joint b. Trapezium 130. Structure I is the: c. Trapezoid a. Second proximal interphalangeal joint d. Capitate b. First carpometacarpal joint 137. Structure F is the: c. Second distal interphalangeal joint a. Hamate d. Second metacarpophalangeal joint b. Trapezium 131. Structure K is the: c. Trapezoid a. Second proximal interphalangeal joint d. Capitate b. First carpometacarpal joint 138. Structure G is the: c. Second distal interphalangeal joint a. Hamate d. Second metacarpophalangeal joint b. Trapezium 164 PART 1 Review and Study Guide

c. Trapezoid Using Figure 6-11, identify the radiographic anatomy of the d. Capitate foot. 139. Structure H is the: a. Hamate b. Trapezium c. Trapezoid A d. Capitate Using Figure 6-10, identify the radiographic anatomy of the B shoulder. C N M A D D E B

C G E

H F L I K

J • Figure 6-10 AP shoulder in external rotation.

140. Structure B is the: • Figure 6-11 Oblique right foot. a. Surgical neck b. Glenoid fossa c. Anatomic neck 144. Structure G is the: d. Greater tubercle a. Talus 141. Structure D is the: b. Navicular a. Surgical neck c. Cuboid b. Lesser tubercle d. Second or intermediate cuneiform c. Scapula 145. Structure H is the: d. Greater tubercle a. Talus 142. Structure E is the: b. Navicular a. Surgical neck c. First or intermediate cuneiform b. Lesser tubercle d. Second or intermediate cuneiform c. Anatomic neck 146. Structure I is the: d. Greater tubercle a. Talus 143. Structure F is the: b. Navicular a. Surgical neck c. Tuberosity b. Semilunar notch d. Second or intermediate cuneiform c. Anatomic neck 147. Structure J is the: d. Greater tubercle a. Talus b. Tuberosity of the calcaneus c. Cuboid d. Second or intermediate cuneiform 148. Structure K is the: a. Fifth metatarsophalangeal joint b. Navicular CHAPTER 6 Challenge Tests 165

c. Cuboid Using Figure 6-13, identify the radiographic anatomy of the d. Second or intermediate cuneiform skull. 149. Structure M is the: a. Talus b. Navicular H I c. Cuboid d. Fifth metatarsophalangeal joint Using Figure 6-12, identify the radiographic anatomy of the J elbow. G K F E

D M A C F B A B E • Figure 6-13 Lateral projection of skull. D C 154. Structure C is the: a. Body of sphenoid b. Occipital bone c. Dorsum sellae d. Anterior clinoid process 155. Structure F is the: a. Body of sphenoid • Figure 6-12 AP elbow. b. Occipital bone c. Dorsum sellae d. Sella turcica 150. Structure A is the: 156. Structure H is the: a. Lateral epicondyle a. Sella turcica b. Olecranon process b. Occipital bone c. Radial head c. Dorsum sellae d. Medial epicondyle d. Anterior clinoid process 151. Structure D is the: 157. Structure M is the: a. Capitulum a. Body of sphenoid (sphenoid sinus) b. Olecranon process b. Occipital bone c. Radial head c. Dorsum sellae d. Ulnar head d. Anterior clinoid process 152. Structure E is the: a. Capitulum b. Olecranon process c. Radial head d. Medial epicondyle 153. Structure H is the: a. Ulnar head b. Olecranon process c. Radial head d. Medial epicondyle 166 PART 1 Review and Study Guide

Using Figure 6-14, identify the radiographic anatomy of the 163. BMI can have an important impact on diagnostic facial bones. imaging. What does BMI stand for? a. Below measurable index b. Body mass in imaging c. Body mass index D d. Body measurement index C 164. Which of the following anatomic structures is not demonstrated on a KUB? a. Bone structure of the pelvis B b. Inferior ribs c. Psoas muscles E d. A Minor calyces 165. Radial deviation is synonymous with: a. Radial flexion b. G Radial deviation c. Ulnar flexion d. Dorsiflexion 166. Which of the following structures is most distal? a. Ascending colon b. Cecum c. Descending colon H d. Sigmoid 167. Rugae may be found in the: J I a. Esophagus • Figure 6-14 Parietoacanthial (Waters) projection of facial bones. b. Stomach c. Small intestine d. Large intestine 158. Structure B is the: a. Zygomatic arch Patient Care (Questions 168-200) b. Foramen magnum 168. An IR can be a source of infection through: c. Bony nasal septum (perpendicular plate of eth- a. Droplet transmission moid and vomer) b. Indirect contact d. Body of maxilla (contains the maxillary sinuses) c. Direct contact 159. Structure C is the: d. Airborne transmission a. Zygomatic arch 169. Anywhere organisms can thrive is the definition of: b. Foramen magnum a. Infection control c. Bony nasal septum (perpendicular plate of eth- b. Infectious waste moid and vomer) c. Universal contamination d. Body of maxilla (contains the maxillary sinuses) d. The reservoir of infection 160. Structure D is the: 170. The abbreviation that stands for a stroke is: a. Zygomatic arch a. hx b. Anterior nasal spine b. Bx c. Bony nasal septum (perpendicular plate of eth- c. CVA moid and vomer) d. MI d. Angle of mandible 171. The prefix that means “false” is: 161. Structure E is the: a. Retro- a. Zygomatic arch b. Endo- b. Foramen magnum c. Pseudo- c. Bony nasal septum (perpendicular plate of eth- d. Epi- moid and vomer) 172. The prefix that means “above” is: d. Body of maxilla (contains the maxillary sinuses) a. Hypo- 162. Beam-part-image receptor alignment is critical in b. Ex- providing: c. Ect- a. A distortion-free image d. Hyper- b. Lower patient dose 173. Infectious waste is placed in containers: c. Higher overall contrast a. Made of lead d. Lower spatial resolution b. Properly labeled with the type of waste therein CHAPTER 6 Challenge Tests 167

c. That are incinerated 183. What is the type of infection control in which micro- d. Made of plastic only organisms have been eliminated as much as possible 174. Needles and syringes must be disposed of: by the use of water and chemical disinfectants? a. Capped a. Medical asepsis b. Weekly b. Surgical asepsis c. Uncapped c. Standard precautions d. Monthly d. Gas sterilization 175. Causing a patient to become apprehensive of being 184. The abbreviation that means “history” is: injured is called: a. hx a. Assault b. bx b. Battery c. hs c. False imprisonment d. MI d. Invasion of privacy 185. The abbreviation that means “heart attack” is: 176. Violation of confidentiality defines: a. hx a. Assault b. HA b. Battery c. CVA c. False imprisonment d. MI d. Invasion of privacy 186. When scheduling radiographic examinations: 177. Neglect or omission of reasonable care defines: a. Schedule barium studies first to get them over a. Respondeat superior with b. Res ipsa loquitur b. Schedule special studies for the afternoon c. Gross negligence c. Schedule barium studies last d. Unintentional misconduct d. Always schedule a scout CT scan first 178. Bradycardia indicates a pulse of: 187. Infectious waste must be handled according to which a. More than 100 beats per minute of the following? b. Fewer than 60 beats per minute a. Radiation protection guidelines c. Greater than 90 beats per minute b. Radiology department rules d. Less than 50 beats per minute c. CDC guidelines 179. Which of the following contains all equipment and d. The condition of the patient drugs needed during respiratory arrest? 188. Normal adult respiration is measured by: a. Crash cart a. Counting breaths b. Suction unit b. Thermometer c. Defibrillator c. Sphygmomanometer d. Sphygmomanometer d. Digital BP cuff 180. Which of the following is used to measure blood pres- 189. What item is used to administer oxygen through the sure? nose? a. Crash cart a. Crash cart b. Suction unit b. Suction unit c. Defibrillator c. Defibrillator d. Sphygmomanometer d. Nasal cannula 181. A positive contrast agent that may be administered 190. What type of infection transmission is defined as to a patient when barium sulfate is contraindicated is being spread primarily on contaminated items, food, called: or water? a. Barium thiosulfate a. Contact transmission b. Iodine b. Airborne transmission c. Air c. Droplet transmission d. Aqueous iodine compound d. Common vehicle transmission 182. Flushing, urticaria, and nausea are symptoms of what 191. Which of the following is used to restore a normal type of contrast agent reaction? heartbeat? a. Local irritation a. Crash cart b. Cardiovascular shock b. Suction unit c. Anaphylactic shock c. Defibrillator d. Psychogenic shock d. Sphygmomanometer 168 PART 1 Review and Study Guide

192. Shock is indicated when the diastolic blood pressure is: c. -ectomy a. Greater than 100 mm Hg d. -megaly b. Less than 60 mm Hg 200. The suffix that means “puncture” is: c. Greater than 90 mm Hg a. -centesis d. Less than 50 mm Hg b. -otomy 193. The law governing patient confidentiality is abbreviated: c. -genic a. CDC d. -osis b. HHS c. ALARA Scoring d. HIPAA Traditionally you have probably focused on how many ques- 194. The type of shock that occurs secondary to heart fail- tions you miss on a test. As you prepare for the certification ure is called: exam, I encourage you to focus on how many you answer a. Hypovolemic shock correctly. Use Table 6-1 to calculate the percentage of ques- b. Septic shock tions you answered correctly in each category and on the c. Neurogenic shock test as a whole. Remember, a score of less than 75% on any d. Cardiogenic shock topic or on an entire test is an indication that more review is 195. Needles and syringes must be disposed of in: needed on that topic. Now go back and concentrate on the a. Lead containers items that were missed and figure out the reason why. Then b. Sharps containers go on to Challenge Test Number 2.

TABLE 6-1 Calculating Your Score for Challenge Test Number 1 Topic Percentage Calculation Your Score

Safety Number correct ______× 100, ÷ 53 = Image Production Number correct ______× 100, ÷ 50 = Procedures Number correct ______× 100, ÷ 64 = Patient Care Number correct ______× 100, ÷ 33 =

Total Number correct ______× 100, ÷ 200 =

Challenge Test Number 2 c. Plastic bags d. Metal pans ARRT Exam Categories: Safety, 196. Used bandages and dressings must be placed into: Image Production, Procedures, a. Lead containers Patient Care b. Waterproof bags and sealed c. Plastic bags Read each question and the answer choices carefully. d. Metal pans Choose the best, most complete answer for each item. Use 197. Infectious waste must be discarded: the results of this test to assess your strengths and weak- a. Immediately nesses. Do not look up any of the answers until you have b. Monthly completed the entire test. Correct the test using the answer c. And burned key in the back of the book. Then compute your scores d. With other hospital waste using Table 6-2 to see where you are strong and where you 198. Toxic chemicals may: need additional review. Refer to the appropriate chapter in a. Be poured down the drain if they do not enter the this book for review of the questions you miss. public water supply b. Never be poured down the drain Safety (Questions 1-53) c. Be poured down the same drain as the processing 1. The amount of radiation deposited per unit length of water tissue traversed by incoming photons is called: d. Be poured down the drain in the restroom only a. Tissue exposure 199. The suffix that means “pain” is: b. Linear deposition of energy a. -itis c. Linear energy transfer b. -algia d. Effective dose limit CHAPTER 6 Challenge Tests 169

2. Cataractogenesis, life span shortening, embryologic 11. The amount of radiation that causes the number of effects, and carcinogenesis are examples of: genetic mutations in a population to double is called the: a. Short-term somatic effects a. Threshold dose b. Genetic effects b. Doubling dose c. Acute radiation syndrome c. Mutagenic dose d. Long-term somatic effects d. Genetic dose 3. Compton interaction: 12. The SI units of equivalent dose, activity, air kerma, a. Increases contrast in the radiographic image and absorbed dose are, respectively: b. Results in scattering of the incident electrons a. Roentgen, rad, rem, curie c. Decreases recorded detail in the radiographic b. Rad, coulomb per kilogram, curie, becquerel image c. Rem, curie, roentgen, rad d. Decreases contrast in the radiographic image d. Sievert, becquerel, graya, grayt 4. Gray t multiplied by a radiation weighting factor 13. Medical x-rays are an example of: equals: a. Natural background radiation a. Air kerma b. Artificially produced radiation b. Becquerel c. Nonionizing radiation c. Sievert d. Ionizing, natural background radiation d. Graya 14. The effective dose limit for a fetus for the entire gesta- 5. Effective dose limit (EfD): tional period is: a. Is the level of radiation that an organism can a. 5.0 mSv receive and probably sustain no appreciable effects b. 0.5 mSv b. Is a safe level of radiation that can be received with c. 0.05 mSv no effects d. 50 mSv c. Should be absorbed annually to maintain proper 15. The photoelectric effect: immunity to radiation a. Results in absorption of the incident photon d. Is 500 mSv per year for the general public b. Results in absorption of the incident electron 6. Radiation with a high LET: c. Produces contrast fog on the radiographic image a. Has low ionization d. Is the same as brems radiation b. Is highly ionizing 16. The annual effective dose limit for radiographers is: c. Carries a low quality factor a. 10 mSv d. Equates with a low RBE b. 100 mSv 7. Radiation protection is based on which dose-response c. 50 mSv relationship? d. 100 mSv a. Linear-threshold 17. The average dose to active bone marrow as an indica- b. Nonlinear-nonthreshold tor of somatic effects on a population is called: c. Linear-nonthreshold a. Doubling dose d. Nonlinear-threshold b. Bone dose 8. Which of the following states that the radiosensitivity c. GSD of cells is directly proportional to their reproductive d. Mean marrow dose activity and inversely proportional to their degree of 18. A radiation dose that if received by the entire pop- differentiation? ulation would cause the same genetic injury as the a. Inverse square law total of doses received by the members actually being b. Law of Bergonié and Tribondeau exposed is called: c. Reciprocity law a. Genetically significant dose d. Ohm’s law b. Doubling dose 9. Which of the following causes about 95% of the cel- c. Mean marrow dose lular response to radiation? d. Genetic dose a. Direct effect 19. A lead apron of at least what thickness should be worn b. Law of Bergonié and Tribondeau while being exposed to scatter radiation? c. Target theory a. 0.25-mm Pb equivalent d. Indirect effect b. 0.50-mm Pb equivalent 10. When radiation strikes DNA, which of the following c. 0.50-mm Al equivalent occurs? d. 0.10-mm Al equivalent a. Direct effect 20. Use of a thyroid shield of at least what thickness b. Law of Bergonié and Tribondeau should be used for fluoroscopy? c. Target theory a. 0.10-mm Pb equivalent d. Indirect effect b. 0.50-mm Pb equivalent 170 PART 1 Review and Study Guide

c. 0.50-mm Al equivalent c. 50 μSv d. 0.10-mm Al equivalent d. 100 μSv 21. How thick are primary protective barriers? 31. The recording material in an OSL dosimeter is: 1 a. ⁄32-inch lead equivalent a. Dilithium 1 b. ⁄16-inch aluminum equivalent b. Lithium fluoride 1 c. ⁄32-inch concrete c. Aluminum oxide 1 d. ⁄16-inch lead equivalent d. Silver halide 22. Primary protective barriers, if in the wall, must extend 32. The energy stored in an OSL dosimeter is released to a height of at least: when the dosimeter is exposed to: a. 5 feet a. Heat b. 6 feet b. White light c. 7 feet c. Laser d. 10 feet d. Ultrasound 23. Secondary protective barriers must extend to a height 33. OSL dosimeters may be worn for: of: a. 1 month a. 5 feet b. 1 week b. 6 feet c. 3 months c. The ceiling d. 1 year d. 10 feet 34. OSL dosimeters may be scanned and reanalyzed: 24. The protective curtain hanging from the fluoroscopy a. Only once tower must be at least: b. Monthly a. 0.50-mm Pb equivalent c. Five times b. 0.25-mm Al equivalent d. An unlimited number of times c. 0.10-mm Pb equivalent 35. The most commonly used gonadal shield is the: d. 0.25-mm Pb equivalent a. Shadow shield 25. The Bucky slot cover must be at least: b. Collimator a. 0.50-mm Pb equivalent c. Contact shield b. 0.25-mm Al equivalent d. Filter c. 0.10-mm Pb equivalent 36. For optimal radiation protection, what type of expo- d. 0.25-mm Pb equivalent sure technique should be used? 26. Filters made of aluminum and copper are placed in a. Low kVp, high mAs the film badge to measure x-ray: b. Small focal spot a. Quantity c. All manual technique b. Source d. High kVp, low mAs c. Energy 37. For optimal radiation protection, what speed of IR d. Type should be used? 27. Film badges are changed: a. Slow a. Quarterly b. Speed has no impact on dose b. Weekly c. Analog c. Yearly d. Fast d. Monthly 38. The minimum source-to-skin distance for portable 28. Thermoluminescent dosimeters use what type of crys- radiography is: tals to record dose? a. At least 12 inches a. Dilithium crystals b. At least 15 inches b. Lithium fluoride c. At least 72 inches c. Flux capacitors d. At least 40 inches d. Bromide crystals 39. How often is added filtration adjusted by the radiog- 29. TLDs are heated and release what type of energy to rapher? indicate dose? a. After several exposures a. Laser b. Daily b. Visible light c. As part of weekly quality control c. X-rays d. Never d. Gamma rays 40. What report does a radiographer consult and initial to 30. Optically stimulated luminescence (OSL) dosimeters verify occupational dose received? provide readings as low as: a. PACS a. 1 μSv b. Dosimeter b. 10 μSv CHAPTER 6 Challenge Tests 171

c. Radiation c. Radioactivity d. Annual dose report d. Pair production 41. What are radiation effects that manifest themselves in 51. Free radicals may recombine to form: the person being irradiated? a. DNA a. Genetic b. Hydrogen peroxide b. Exposed cell c. Sulfuric acid c. Somatic d. New cytoplasm d. Molecular 52. What is the thickness of a thyroid shield that should 42. What type of background radiation is radon? be worn during fluoroscopy? a. Man-made a. 0.10-mm lead equivalent b. Radioactive water b. 0.50-mm lead equivalent c. Natural c. 0.50-mm aluminum equivalent d. Natural form of electromagnetic waves d. 0.10-mm aluminum equivalent 43. The photoelectric effect is responsible for: 53. For shielding purposes, what is the x-ray control a. The brightness of the image booth considered? b. Producing scatter radiation a. Secondary protective barrier c. Differential absorption of the x-ray beam by the b. Primary protective barrier body c. Equivalent to a lead apron d. Spatial resolution d. A tertiary protective barrier 44. The unit of measurement that is determined by measuring ions produced in air as radiation passes through Image Production (Questions 54-103) it is the: 54. An ionization chamber circuit places: a. Becquerel a. A photomultiplier tube between the IR and the b. Gray patient c. Air kerma b. An ionization chamber beneath or behind the IR d. Sievert c. An ionization chamber between the patient and 45. One (1) is the radiation weighting factor (WR) for: the x-ray tube a. Neutrons d. An ionization chamber between the IR and the b. Gamma rays patient c. Cosmic rays 55. Full-wave rectification uses: d. Radon a. A single semiconductor 46. Atomic number is represented by the letter: b. Four silicone-based semiconductors a. M c. The x-ray tube as a semiconductor b. A d. Four silicon-based semiconductors c. Z 56. A full-wave rectified, three-phase, 12-pulse x-ray d. Q machine produces approximately ____% more aver- 47. Atomic mass is represented by the letter: age photon energy than a full-wave rectified, single- a. M phase x-ray machine. b. A a. 35 c. Z b. 50 d. Q c. 41 48. The primary purpose of filtering the x-ray beam is to: d. 100 a. Increase contrast 57. According to the anode heel effect, the intensity of b. Improve radiation protection radiation is greater at the ______side of the x-ray c. Soften the beam for proper imaging tube. d. Remove short-wavelength rays a. Anode 49. Considering probability, x-ray photons will probably b. Central x-ray strike: c. Neither side; the beam is of uniform intensity a. The nucleus d. Cathode b. RNA 58. The amount of time needed for an AEC to terminate c. DNA the exposure is called: d. Water a. Exposure latitude 50. X-ray photons depositing their energy in the water of b. Minimum reaction time the cytoplasm may cause: c. Chamber response time a. Electrolysis d. Electronic time b. Radiolysis 172 PART 1 Review and Study Guide

Using Figure 6-15, answer questions 59 through 62. 64. An outpatient radiographic room is used primarily for tabletop radiography of the extremities. On a particularly busy afternoon, the radiographers find that A similar exposure techniques on successive patients result in substantially different radiographs. Which of the following would lead to an accurate diagnosis of the problem? a. Contrast test pattern B b. Measurement of HVL c. Use of a digital dosimeter to determine exposure reproducibility d. Use of a digital dosimeter to determine exposure linearity 65. X-ray beam quality is expressed in terms of: a. Half-value layer b. Exposure linearity D c. Exposure reproducibility d. mAs 66. The accuracy of collimation at a 40-inch SID must be: C a. ± 4 inches 8 • Figure 6-15 b. ± ⁄10 inch c. ± 1 inch 1 d. ± ⁄10 inch 59. Where is the electron beam focused? 67. The accuracy of kVp at 80 kVp must be: a. A a. Within 5% b. B b. Within 10% c. C c. Within 15% d. D d. Within 20% 60. Where is light energy converted to electrons? 68. The apparent size of the focal spot as viewed by the a. A image receptor is called the: b. B a. Actual focal spot c. C b. Target angle spot d. D c. Anode heel effect 61. From where is the visible image distributed to viewing d. Effective focal spot or recording media? 69. Which of the following interactions is the primary a. A source of diagnostic x-rays? b. B a. Photoelectric effect c. C b. Bremsstrahlung d. D c. Compton 62. Where is x-ray energy converted to visible light? d. Pair production a. A 70. Which set of exposure factors would produce the b. B greatest receptor exposure? c. C a. 100 mAs, 70 kVp, 0.5-mm focal spot, 60-inch SID d. D b. 200 mAs, 60 kVp, 1.2-mm focal spot, 60-inch SID 63. A particular x-ray room is “shooting dark.” The prob- c. 100 mAs, 70 kVp, 1.2-mm focal spot, 60-inch SID lem arises when a change is made from 200 to 300 mA d. 300 mAs, 90 kVp, 0.5-mm focal spot, 60-inch SID using fixed kVp techniques at 0.16 second. Which of 71. Which set of exposure factors would produce the low- the following would lead to an accurate diagnosis of est receptor exposure? the problem? a. 80 mAs, 85 kVp, 40-inch SID, 1.2-mm focal spot a. Resolution test pattern b. 40 mAs, 60 kVp, 40-inch SID, 0.5-mm focal spot b. Measurement of HVL c. 160 mAs, 70 kVp, 40-inch SID, 1.2-mm focal spot c. Use of a digital dosimeter to determine exposure d. 160 mAs, 90 kVp, 40-inch SID, 0.5-mm focal spot reproducibility 72. The components of a grid are: d. Use of a digital dosimeter to determine exposure a. Pb strips and Pb interspacers linearity b. Al strips and Pb interspacers c. Pb strips and Al interspacers d. Pb strips and cardboard interspacers CHAPTER 6 Challenge Tests 173

73. Which of the following lists of substances that make 82. A term used to describe the mathematical formula up the human body best places them in increasing used by the computer to reconstruct the image is: order of density? a. Bit depth a. Air, fat, water, muscle, bone b. Algorithm b. Bone, muscle, water, fat, air c. Mathematical function c. Air, fat, muscle, water, bone d. Exposure equation d. Air, fat, water, muscle, bone, tooth enamel 83. When speed is essential in completing an imaging 74. Bit depth describes: examination, the preferred IR is: a. The available gray scale of an imaging system a. CR b. Window level b. DR c. Spatial resolution c. Wireless DR plate d. Optimum exposure needed for an imaging system 84. Pixel is an acronym meaning: 75. If it is necessary to reduce exposure by half, and it is a. Detector element impossible to do so by changing mAs, the radiogra- b. Picture element pher may: c. Volume element a. Reduce SID by half d. Bit element b. Double SID 85. Improper use of grids with a digital imaging system c. Decrease kVp by 15% may cause an artifact known as: d. Decrease kVp by 50% a. Moiré pattern 76. The dynamic range for digital imaging is: b. Grid cutoff a. Wide c. Motion artifact b. Narrow d. Quantum mottle c. Unrelated to diagnostic imaging 86. An integrated system of images and information is 77. Dynamic range is defined as: called: a. The range of exposures over which a detector can a. DICOM acquire image data b. DDR b. Exposure latitude c. CR/DDR c. Window width d. PACS d. Window level 87. Image noise may be described as: 78. Modulation transfer function (MTF) is: a. Undesirable fluctuations in brightness a. The controlling factor of contrast resolution b. Undesirable fluctuations in contrast b. A measure of the ability of the imaging system to c. Inadequate spatial resolution preserve signal contrast as a function of the spatial d. A function of mAs resolution 88. The measurement of the luminance of a monitor is c. A function of exposure called: d. A function of pixel density a. Density 79. 2n (where n equals the number of bits) defines: b. Contrast a. Pixel density c. Brightness b. Shades of gray d. Detail visibility c. Bit depth 89. Grid radius is: d. Detector element size a. The total amount of lead in a grid 80. A scintillator: b. The range of SIDs that may be used with a focused a. Absorbs x-ray energy and emits part of that energy grid as visible light c. The objective plane b. Absorbs x-ray energy and emits that energy as elec- d. H/D trons 90. Visibility of an object’s edge may be limited by: c. Converts visible light into electrons a. Speed class d. Converts electrons into visible light b. Modulation transfer function 81. The magnitude of the signal differences in the rem- c. Contrast resolution nant beam refers to: d. Quantum noise a. Subject contrast 91. Detective quantum efficiency indicates: b. IP contrast a. Patient dose c. Window level b. Potential speed class d. Spatial resolution c. Spatial resolution d. Contrast resolution 174 PART 1 Review and Study Guide

92. Digital receptors have what kind of response to expo- 103. The amount of lead in a grid is referred to as: sure? a. Grid frequency a. Nonlinear b. Grid ratio b. Linear c. Grid radius c. Curvilinear d. Grid cleanup ability d. Hyperlinear 93. If the angle on the anode is decreased, what effect is Procedures (Questions 104-167) there on spatial resolution? 104. For the parietoacanthial projection (Waters) for a. Increases the sinuses, the OML forms an angle of how many b. Decreases degrees with the cassette? c. No appreciable effect a. 53 94. If mAs is increased four times, what is the effect on b. 45 receptor exposure? c. 25 a. Increases d. 37 b. Decreases 105. For the PA axial projection for the colon, the central c. No appreciable effect ray is angled caudad how many degrees? 95. If SID is increased, what is the effect on IR exposure? a. 10 to 20 a. Increases b. 20 to 30 b. Decreases c. 30 to 40 c. No appreciable effect d. 25 to 45 96. If OID is decreased, what is the effect on spatial reso- 106. The carpal bones are arranged in two rows as follows: lution? a. Proximal row (scaphoid, lunate, triquetral, pisi- a. Increases form) and distal row (trapezium, trapezoid, capi- b. Decreases tate, hamate) c. No appreciable effect b. Distal row (scaphoid, lunate, triquetral, pisiform) 97. A photodiode converts: and proximal row (trapezium, trapezoid, capitate, a. AC to DC hamate) b. Light into a charge c. Proximal row (scaphoid, triquetral, capitate, pisi- c. Electrons into light form) and distal row (trapezium, trapezoid, lunate, d. MRI signal into PACS data hamate) 98. If kVp is increased, what happens to attenuation of d. The carpals are not arranged in rows the beam in the patient? 107. The prominent point of the elbow is called the: a. Increase a. Olecranon, part of the radius b. Decrease b. Semilunar notch c. No appreciable effect c. Trochlea 99. In a conversion from a nongrid to a 12:1 grid, what d. Olecranon, part of the ulna happens to image contrast? 108. Imaging of what pathologic condition would require a. Increases radiography of the cervical spine? b. Decreases a. Talipes c. No appreciable effect b. Colles fracture 100. If SID is decreased from 60 inches to 30 inches, what c. Ankylosing spondylitis happens to magnification? d. Jefferson fracture a. Increases 109. Imaging of what pathologic condition would require b. Decreases radiography of the hand? c. No appreciable effect a. Talipes 101. If the IR is moved from tabletop to Bucky, what hap- b. Colle fracture pens to spatial resolution? c. Boxer fracture a. Increases d. Ankylosing spondylitis b. Decreases 110. Imaging of what pathologic condition would require c. No appreciable effect radiography of the distal forearm? 102. If there is a decrease in source-to-object distance, a. Talipes what happens to spatial resolution? b. Colle fracture a. Increases c. Boxer fracture b. Decreases d. Ankylosing spondylitis c. No appreciable effect CHAPTER 6 Challenge Tests 175

111. Imaging of what pathologic condition would require c. Radius radiography of the feet? d. Humerus a. Talipes 116. The structure designated as IV is the: b. Colle fracture a. Lunate c. Boxer fracture b. Triquetral d. Ankylosing spondylitis c. Capitate 112. Imaging of what pathologic condition would require d. Pisiform radiography of the entire spine? 117. The structure designated as V is the: a. Talipes a. Lunate b. Colle fracture b. Scaphoid c. Boxer fracture c. Trapezium d. Ankylosing spondylitis d. Trapezoid Using Figure 6-16, answer questions 113 through 118. 118. The structure designated as VI is the: a. Lunate b. Triquetrum I c. Capitate d. Scaphoid Using Figure 6-17, answer questions 119 through 123.

V IV III II I

V IV

III • Figure 6-17

• Figure 6-16 119. The structure designated as I is the: a. Head of ulna 113. The structure designated as I is the: b. Radial head a. Carpometacarpal joint c. Medial epicondyle b. Interphalangeal joint d. Lateral epicondyle c. Proximal phalanx 120. The structure designated as II is the: d. Distal interphalangeal joint a. Coronoid fossa 114. The structure designated as II is the: b. Olecranon a. Carpometacarpal joint c. Semilunar notch b. Interphalangeal joint d. Radial head c. Proximal phalanx 121. The structure designated as III is the: d. Metacarpophalangeal joint a. Head of the ulna 115. The structure designated as III is the: b. Radial head a. Ulna c. Medial epicondyle b. Metacarpal d. Lateral epicondyle 176 PART 1 Review and Study Guide

122. The structure designated as IV is the: Using Figure 6-19, answer questions 129 through 132. a. Medial epicondyle b. Trochlea III c. Lateral epicondyle d. Ulnar head II 123. The structure designated as V is the: IV a. Medial epicondyle b. Trochlea I c. Lateral epicondyle d. Ulnar head Using Figure 6-18, answer questions 124 through 128.

III

• Figure 6-19 II V • Figure 6-18 129. The structure designated as I is the: a. Head of the fibula 124. The structure designated as I is the: b. Head of the tibia a. Pedicle c. Tuberosity b. Superior vertebral notch d. Styloid process c. Interior vertebral notch 130. The structure designated as II is the: d. Lamina a. Medial condyle 125. The structure designated as II is the: b. Lateral condyle a. Pedicle c. Intercondylar eminence b. Superior vertebral notch d. Head of the fibula c. Interior vertebral notch 131. The structure designated as III is the: d. Spinous process a. Tubercle 126. The structure designated as III is the: b. Lateral condyle a. Lamina c. Medial condyle b. Spinous process d. Intercondylar eminence c. Superior articular process 132. The structure designated as IV is the: d. Pedicle a. Tubercle 127. The structure designated as IV is the: b. Lateral condyle a. Superior vertebral notch c. Medial condyle b. Superior articular process d. Intercondylar eminence c. Transverse process d. Spinous process 128. The structure designated as V is the: a. Lamina b. Spinous process c. Inferior vertebral notch d. Inferior articular process CHAPTER 6 Challenge Tests 177

Using Figure 6-20, answer questions 133 through 138. 139. Critique Figure 6-21. a. Radiograph is unacceptable; radius and ulna VI should be superimposed IV b. Radiograph is unacceptable; tibia and fibula II should be superimposed c. Radiograph is acceptable, but only one joint is needed d. Radiograph is acceptable

V III

• Figure 6-20

133. The structure designated as I is the: a. Vertebral border b. Scapular notch c. Body d. Axillary border 134. The structure designated as II is the: a. Humeral head b. Acromion c. Coracoid process d. Coronoid process 135. The structure designated as III is the: a. Vertebral border b. Scapular notch c. Body d. Subscapular fossa 136. The structure designated as IV is the: a. Coracoid process b. Coronoid process • Figure 6-21 c. Scapular notch d. Glenoid fossa 137. The structure designated as V is the: a. Glenoid fossa b. Acromion c. Coronoid process d. Coracoid process 138. The structure designated as VI is the: a. Glenoid fossa b. Acromion c. Coronoid process d. Coracoid process 178 PART 1 Review and Study Guide

140. The radiograph inFigure 6-22 illustrates what region? 142. Critique Figure 6-24. a. Genitourinary a. Radiograph was taken with interpupillary line par- b. Cardiovascular allel to IR c. Hepatobiliary b. Radiograph was taken with MSP perpendicular to d. Gastrointestinal IR c. Radiograph was taken with interpupillary line perpendicular to IR d. Radiograph was taken with MSP parallel to central ray

• Figure 6-22

141. Critique Figure 6-23. a. Radiograph unacceptable; arm rotated b. Radiograph acceptable for medial oblique c. Radiograph acceptable for lateral oblique • Figure 6-24 d. Radiograph unacceptable; humerus and forearm must be in same plane

• Figure 6-23 CHAPTER 6 Challenge Tests 179

143. Critique Figure 6-25. Using Figure 6-26, answer questions 144 through 148. a. Radiograph was taken with central ray angled 15 144. The structure designated as I is the: degrees caudad a. Pars interarticularis b. Radiograph was taken with central ray angled 0 b. Superior articular process degrees c. Pedicle c. Radiograph was taken with central ray angled 15 d. Lamina degrees cephalad d. Radiograph was taken with MSP perpendicular to central ray I

III

• Figure 6-26

145. This illustrates which type of vertebra? a. thoracic b. cervical c. lumbar 146. The structure designated as III is the: a. Spinous process b. Transverse process c. Pedicle d. Inferior articular process 147. The structure designated as IV is the: a. Spinous process b. Transverse process c. Pedicle • Figure 6-25 d. Pars interarticularis 148. The structure designated as V is the: a. Spinous process b. Transverse process c. Pedicle d. Inferior articular process 149. The lateral transthoracic humerus, oblique sternum, and lateral thoracic spine may be imaged best by using: a. Short exposure time b. Breathing technique c. Image intensifier d. CT 180 PART 1 Review and Study Guide

150. A patient unable to supinate the hand for an antero- 158. When the PA oblique projection for the sacroiliac posterior (AP) projection of the forearm: joints is performed, the side of interest is: a. Should be made to do so to provide a diagnostic a. Farthest from the image receptor radiograph b. Closest to the image receptor b. Probably has a fracture of the radial head and must c. Rotated 10 degrees be handled carefully d. Rotated 45 degrees c. Probably has a low pain tolerance and must be 159. Routine chest radiography is performed: handled carefully a. At the end of full inspiration d. May require radiographs with and without weights b. At the end of full expiration 151. When a posteroanterior (PA) axial projection of the c. At the end of the second full inspiration clavicle is performed, the central ray should be angled: d. With the patient supine or upright a. 15 degrees cephalad 160. The primary purpose of performing oblique projec- b. 15 degrees caudad tions of the ribs is: c. 25 to 30 degrees cephalad a. To image the axillary portion of the ribs d. 25 to 30 degrees caudad b. To image the ribs above the diaphragm 152. When a lateral projection of the knee is performed, c. To image the ribs below the diaphragm the knee should be: d. To determine the extent of the patient’s pain a. Extended 20 to 30 degrees tolerance b. Flexed to a 90-degree angle 161. When the PA projection of the skull is performed to c. Flexed 20 to 30 degrees image the frontal bone: d. Fully extended 1. The central ray is directed perpendicular to the IR 153. When a tangential projection of the patella is per- 2. The OML is perpendicular to the IR formed with the patient prone, the central ray should 3. The central ray exits at the glabella be angled: 4. MSP is parallel to the cassette a. 15 degrees cephalad a. All are true b. 15 degrees caudad b. 1, 2 c. 25 degrees cephalad c. 1, 3, 4 d. 45 degrees cephalad d. 1, 3 154. Use of which of the following would provide an 162. Which of the following bones has (have) no body? improved image of the femur? a. Atlas a. Wedge filter b. Axis b. Anode heel effect c. Thoracic vertebrae c. Short SID d. Lumbar vertebrae d. Long OID 163. This forms the medial part of the anterior chest wall: 155. When an AP projection of the hip is performed, the a. Manubrium central ray is directed: b. Floating a. Perpendicular to a point 2 inches medial to the c. Xiphoid anterior superior iliac spine (ASIS) at the level of d. Sternum the superior margin of the greater trochanter 164. Which of the following is (are) located just below the b. Parallel to a point 2 inches medial to the ASIS at head of the humerus? the level of the superior margin of the greater tro- a. Greater and lesser tubercles chanter b. Bicipital groove c. At a 15-degree cephalad angle c. Capitulum d. To the level of the ASIS d. Trochlea 156. When an AP oblique projection is performed for the 165. Blood vessels, the bronchial tree, and nerves enter the cervical vertebrae, the central ray is directed: lungs at this point: a. 25 to 30 degrees cephalad a. Trachea b. 15 to 20 degrees caudad b. Left lung c. 5 to 10 degrees cephalad c. Right lung d. 15 to 20 degrees cephalad d. Hilus 157. When the AP oblique projection is performed for the 166. The narrow distal end of the stomach that connects lumbar vertebrae, the side of interest is: with the small intestine is called the: a. Farthest from the image receptor a. Rugae b. Closest to the image receptor b. Pylorus c. Rotated 30 degrees c. Fundus d. Rotated 20 degrees d. Greater curvature CHAPTER 6 Challenge Tests 181

167. The part of the urinary system located between the c. Nasogastric tube renal pelvis and the bladder is called the: d. Ventilator tube a. Cortex 177. Nosocomial infections are acquired: b. Medulla a. In radiology c. Nephron b. Through the nose d. Ureter c. During cold and flu season d. In the health care setting Patient Care (Questions 168-200) 178. During movement and transfer of patients, urinary 168. The first tier of transmission-based isolation precau- catheter bags should be: tions is called: a. Safely placed on the patient’s abdomen a. Universal precautions b. Kept below the level of the urinary bladder b. Standard precautions c. Kept below the level of the x-ray table c. Infection control d. Kept on the cart or wheelchair d. Liner, nonthreshold 179. The first task that must be performed when beginning 169. The first step in pouring liquids into containers in a a radiographic examination of a patient is to: sterile field is to: a. Verify patient identity a. Allow the liquid to drop onto the sterile field b. Determine accuracy of physician’s orders b. Pour a small amount into a waste receptacle to c. Verify the examination to be performed cleanse the lip of the bottle d. Remove radiopaque objects from the area of interest c. Carefully determine the contents of the container 180. Which of the following is not required for valid con- d. Immediately pour the solution when requested to sent? do so a. Patient must be of legal age 170. What is usually used to perform medical asepsis? b. Patient must be adequately informed and sign a a. Water and chemicals consent form b. Complete sterilization procedure c. Patient must be mentally competent c. Surgical suite procedures d. Consent must be offered voluntarily d. Soap and water 181. The prefix that means “around” is: 171. The suffix that means “condition” is: a. Poly- a. -pathy b. Peri- b. -itis c. Retro- c. -osis d. Trans- d. -tomy 182. The prefix that means “many” is: 172. The suffix that means “disease” is: a. Peri- a. -osis b. Poly- b. -pathy c. Hemi- c. -rhaphy d. Epi- d. -scopy 183. A system that uses barriers between individuals and 173. Bradycardia indicates a pulse of: assumes all patients are infectious is called: a. Greater than 100 beats per minute a. Standard precautions b. Greater than 60 beats per minute b. Whole-body isolation c. Greater than 90 beats per minute c. Sterile technique d. Less than 60 beats per minute d. Surgical asepsis 174. Normal adult respiration is: 184. When you are performing patient care in radiology: a. Greater than 100 beats per minute a. Hands should be washed after each procedure b. Less than 60 beats per minute b. Gowns and gloves should always be worn c. 12 to 16 breaths per minute c. Hands should be washed only after you care for d. 12 to 16 beats per minute obviously infectious patients 175. The radiographer must be proficient in the use of d. Gloves should be worn only when you perform which of the following medical instruments? gastrointestinal procedures or venipuncture a. Angiography catheter 185. Patient transfer from cart to x-ray table should be per- b. Sphygmomanometer formed: c. Thermometer a. Alone when working evenings or nights d. Oxygen administration equipment b. By radiographers working in pairs at all times 176. A tube used to feed a patient or to perform gastric c. Alone when the department is busy or has a staff suction is called a: shortage a. Tracheostomy tube d. In pairs only when other radiographers are avail- b. Tracheotomy tube able to assist 182 PART 1 Review and Study Guide

186. Your best source for the latest information regarding 5. Providing comfort and communicating quietly standard precautions is the: with the patient, whether the patient is con- a. Radiology administrator scious or unconscious b. Radiology purchasing manager a. 1, 3 c. Infection control department b. 4, 5 d. Radiologist c. 1, 3, 5 187. After all radiographic or fluoroscopic procedures, the d. 1, 3, 4, 5 radiographer should use ______to clean surfaces 193. For a barium enema, the contrast agent should be with which the patient was in contact. mixed with: a. Alcohol a. Cold water b. Surgical asepsis b. Water at or below body temperature c. Soap and water c. Water at approximately 120° F d. Medical asepsis d. Water at approximately 100° F 188. When sterile fields are prepared, damp packages: 194. All iodinated contrast media used today contain: a. Are always considered contaminated a. Iodine and free ions b. Are always considered sterile because the damp- b. Free ions ness confirms they were cleaned c. Only iodine c. Should be unwrapped first and placed in the cen- d. Salts of organic iodine compounds ter of the sterile field 195. The highest incidence of contrast agent reactions d. Are always considered sterile; the dampness is a occurs with the use of: remnant of the gassing process a. Negative contrast media 189. When mobile radiography is performed, the mobile b. Ionic iodinated contrast media unit: c. Nonionic iodinated contrast media a. Does not have to be cleaned because it is never in d. Barium sulfate contact with sterile fields 196. It is important for the radiographer to obtain the b. Must be cleaned before and after each use recent history of radiographic examinations per- c. Must be cleaned before it is brought into surgical formed on a patient so that: areas or reverse isolation units a. An overdose of iodinated contrast media does not d. Must be cleaned before it is brought into surgical occur from examinations recently performed areas or reverse isolation units and after its removal b. An overdose of radiation is not administered from most isolation units c. Unnecessary examinations may be avoided 190. When radiography is performed on patients in isola- d. Costs may be contained tion, the IR: 197. For a patient who has a history of intravenous urogra- a. Should be placed in a protective covering only if phy and no contrast agent reactions: the patient is in reverse isolation a. The radiographer may assume there would be no b. Must always be placed in a protective covering reaction on subsequent intravenous urograms c. Should be placed in a protective covering to keep b. The radiographer must assume there is a chance of it free of microbes a reaction on other contrast examinations d. Should be placed in a protective covering so that c. The radiographer must assume there is a chance no microbes leave the room of a reaction on subsequent intravenous uro- 191. Which of the following procedures should a radiogra- grams pher be prepared to assist with at any time? d. There is no chance of reactions on subsequent a. Cardiac massage intravenous urograms b. Defibrillation 198. A negative contrast agent used in chest radiography c. Feeding tube insertion and some arthrography is: d. CPR a. Barium sulfate 192. In addition to performing radiography on a trauma b. Iodine victim, the radiographer should be: c. Perforated ulcers or ruptured appendix 1. Assessing the patient’s condition continually d. Air 2. Interpreting the images for the emergency de- 199. A positive contrast agent administered to the patient partment physician who is going to surgery is: 3. Taking additional projections as indicated by the a. Barium sulfate patient’s condition or preliminary images b. Iodine 4. Keeping all other health care workers out c. Perforated ulcers or ruptured appendix of the room because of radiation protection d. Aqueous iodine compound standards CHAPTER 6 Challenge Tests 183

TABLE 6-2 Calculating Your Score for Challenge Test Number 2 Topic Percentage Calculation Your Score

Safety Number correct ______× 100, ÷ 53 = Image Production Number correct ______× 100, ÷ 50 = Procedures Number correct ______× 100, ÷ 64 = Patient Care Number correct ______× 100, ÷ 33 =

Total Number correct ______× 100, ÷ 200 =

200. In an attempt to maintain the quality of patient care c. Nonionizing radiation at the highest level possible over time, proof of con- d. Primary radiation tinuing education is mandatory for renewal of certifi- 2. The photon-tissue interaction in diagnostic radiogra- cation with: phy that results in the total absorption of an x-ray a. State licensing boards in all 50 states photon and the production of contrast in the radio- b. American Society of Radiologic Technologists graphic image is: c. The Joint Commission a. Compton d. ARRT b. Coherent c. Photoelectric Scoring d. Pair production Use Table 6-2 above to calculate the percentage of questions 3. Which photon-tissue interaction produces a recoil you answered correctly in each category and on the test as electron and a scattered photon in diagnostic radiog- a whole. Remember, a score of less than 75% on any topic raphy? or the entire test is an indication that more review is needed a. Compton on that topic. Now go back and concentrate on which items b. Coherent were missed and the reason why. When you are done review- c. Photoelectric ing, go on to Challenge Test Number 3. d. Pair production 4. The SI unit of exposure in air is the: Challenge Test Number 3 a. Air kerma b. Gray ARRT Exam Categories: Safety, c. Becquerel Image Production, Procedures, d. Sievert Patient Care 5. The SI unit of absorbed dose is the: a. LET Read each question and the answer choices carefully. b. Gray Choose the best, most complete answer for each item. c. Curie Use the results of this test to assess your strengths and d. Sievert weaknesses. Do not look up any of the answers until you 6. The SI unit of equivalent dose is the: have completed the entire test. Correct the test using the a. Sievert answer key in the back of the book. Then compute your b. Gray scores using Table 6-3 to see where you are strong and c. Radiation weighting factor where you need additional review. Refer to the appropri- d. LET ate chapter in this book for review of the questions you 7. The SI unit of effective dose is the: miss. a. Sievert b. Gray Safety (Questions 1-53) c. Radiation weighting factor For the following questions, choose the single best answer. d. LET 1. Radiation that exits the x-ray tube from the anode is 8. The SI unit of radioactivity is the: called: a. Becquerel a. Remnant radiation b. Gray b. Gamma radiation c. Quality factor d. Curie 184 PART 1 Review and Study Guide

9. ______refers to energy per unit mass absorbed by 18. Which of the following would be applicable to radia- an object. tion therapy? a. Bq a. Inverse square law b. Gy a b. Law of Bergonié and Tribondeau c. WR c. Reciprocity law d. Gy t d. Ohm’s law 10. The amount of radiation deposited per unit length of 19. Which of the following causes about 5% of the cel- tissue traversed by incoming photons is called: lular response to radiation? a. REM a. Direct effect b. RADS b. Law of Bergonié and Tribondeau c. LET c. Target theory d. RPU d. Indirect effect 11. The weighting factor related to radiation effects in 20. When radiation strikes the cytoplasm, which of the organs and tissues is: following occurs? a. WR a. Direct effect b. Gy a b. Law of Bergonié and Tribondeau c. Gy t c. Target theory d. WT d. Indirect effect 12. Compton interaction: 21. The equivalent dose limit for the embryo-fetus is: a. Produces poorer recorded detail in the radio- a. 500 mSv per year graphic image b. 0.5 mSv per month b. Results in absorption of the incident photon c. 0.05 rem per month c. May produce higher contrast on the radiograph d. 0.5 mSv during gestation d. May produce a gray fog on the image, lowering 22. The effective dose limit for radiographers for localized contrast areas of skin is: 13. The radiation weighting factor for x-rays is: a. 50 mSv per year a. 10 b. 500 mSv per year b. 1 c. 0.5 mSv monthly c. 20 d. 10 mSv monthly d. 5 23. The cumulative occupational exposure for a 48-year- 14. Mutations are examples of: old radiographer is: a. Short-term somatic effects a. 48 mSv b. Genetic effects b. 480 mSv c. Acute radiation syndrome c. 24 mSv d. Long-term somatic effects d. 0.48 mSv 15. Effective dose limit is: 24. The annual effective dose limit for the general public, a. The level of radiation that an organism can receive assuming infrequent exposure, is: before formation of cancer a. 5 mSv b. Age × 1 mSv for occupationally exposed individuals b. 500 mSv c. 50 mSv per month for occupationally exposed c. 0.5 mSv individuals d. 50 mSv d. 50 mSv per year for occupationally exposed indi- 25. The upper boundary dose that can be absorbed that viduals carries a negligible risk of somatic or genetic damage 16. What agency publishes radiation protection recom- to the individual defines: mendations? a. Maximum permissible dose a. ICRP b. ALARA b. NCRP c. Law of Bergonié and Tribondeau c. NRC d. Effective dose limit d. ASRT 26. Compared with OSL and TLD badges, film badges 17. Radiation safety standards assume what relationship are: between dose and response? a. more sensitive a. Linear-threshold b. less sensitive b. Nonlinear-nonthreshold c. the same sensitivity c. Linear-nonthreshold d. Nonlinear-threshold CHAPTER 6 Challenge Tests 185

27. The exposure switch on a portable x-ray machine 36. Areas occupied by persons trained in radiation safety must be attached to a cord that is at least how many and wearing personnel monitoring devices are called: feet long? a. Controlled areas a. 3 b. Uncontrolled areas b. 6 c. Off-limits areas c. 12 d. Radiation areas d. 2 37. Which of the following takes into account the volume 28. Under what conditions can the radiographer be and types of examinations performed in the room? exposed to the primary beam? a. Use factor a. When performing mobile radiography, as long as b. Shielding factor the exposure is low c. Volume factor b. Never, under any conditions d. Workload c. When performing cross-table projections, if 38. How is workload factor measured? needed to hold the cassette in place a. Half-value layer d. When assisting with fluoroscopy b. Amount of time the beam is on 29. For purposes of radiation protection, the x-ray beam c. mA minutes per week is filtered. X-ray tubes operating above 70 kVp must d. Average kVp per week have total filtration of: 39. The amount of time the beam is on and directed at a a. At least 0.25-mm aluminum equivalent particular barrier is called: b. At least 0.25-mm lead equivalent a. Use factor c. No more than 2.5-mm aluminum equivalent b. Shielding factor d. At least 2.5-mm aluminum equivalent c. Occupancy 30. Gonadal shielding should be used: d. Workload a. On every examination performed 40. Leakage radiation from a diagnostic x-ray tube may b. Whenever it does not obstruct the area of clinical not exceed: interest a. 1 mGya per hour, measured at the source c. Only on children and women of childbearing age b. 10 mGya per hour d. Only during pregnancy c. 1 mGya per hour, measured at 1 m from the housing 31. The secondary protective barrier must overlap the pri- d. 100 mGya per hour, measured at 1 m from the mary protective barrier by at least: housing 1 a. ⁄10 inch 41. Organelles are located in the: b. 1 inch a. DNA c. 1 foot b. Cytoplasm d. ½ inch c. RNA 32. The x-ray control booth is considered a: d. Cellular nucleus a. Secondary protective barrier 42. Relative biological effectiveness (RBE) describes the: b. Primary protective barrier a. Ability of radiation to produce biological damage c. Mobile barrier b. Efficacy of radiation therapy d. Nonbarrier c. Sensitivity of DNA to radiation exposure 33. The exposure switch must keep the radiographer d. Radiosensitivity of water in the cytoplasm behind the: 43. The law of Bergonié and Tribondeau states: a. Primary protective barrier a. Radiation intensity is inversely proportional to the b. Secondary protective barrier square of the distance c. X-ray tube b. Cells are most sensitive to radiation when they are d. Door immature, undifferentiated, and rapidly dividing 34. Areas for the general public, such as waiting rooms c. Voltage is equal to current times resistance and stairways, are considered: d. All radiation exposure causes damage to the cell a. Controlled areas 44. Which of the following describes the radiosensitivity b. Uncontrolled areas of lymphocytes? c. Off-limits areas a. Low radiosensitivity d. Radiation areas b. Least radiosensitive cells in the body 35. An uncontrolled area must be kept under what dose c. Most radiosensitive cells in the body weekly? d. There is no connection between lymphocytes and a. 5 μSv radiation exposure b. 10 μSv 45. When are embryologic effects least likely to occur? c. 15 μSv a. During the final trimester of gestation d. 20 μSv b. During the middle trimester of gestation 186 PART 1 Review and Study Guide

c. During the first trimester of gestation 55. The filament circuit makes use of what type of trans- d. At conception former? 46. Lead aprons must be worn to protect against which a. Step-up photon–tissue interaction? b. Autotransformer a. Compton c. Step-down b. Coherent d. Falling load c. Photoelectric interaction 56. Because the x-ray tube requires DC to operate prop- d. Pair production erly, what device is required in the x-ray circuit? 47. What is plotted on the x-axis of a dose-response curve? a. Autotransformer a. Dose b. Step-up transformer b. Response c. Rectifier c. Receptor exposure d. Falling load generator d. Radioactivity 57. Where is the rectifier located in the x-ray circuit? 48. What is the preferred source-to-skin distance for a. Between the timer and the step-up transformer C-arms? b. Between the step-up transformer and the step- a. 12 inches down transformer b. 10 inches c. Between the primary and secondary coils of the c. 20 inches step-up transformer d. 15 inches d. Between the step-up transformer and the x-ray 49. Photoelectric interaction occurs at what level in the tube atom? 58. Thermionic emission occurs at the: a. L-shel a. Anode b. K-shell b. Control panel c. M-shel c. Rectifier d. Outer shell d. Cathode 50. Radiation exiting the patient in very divergent paths 59. At the time of exposure, the charge on the focusing would be indicative of cup is: a. Photoelectric rays a. Irrelevant b. Scatter b. Positive c. Coherent interaction c. Negative d. Patient motion during the exposure d. Alternating 51. Cellular components contained in the cytoplasm are 60. An interaction that produces heat at the anode and called also produces x-rays is called: a. Free radicals a. Characteristic b. Ions b. Photoelectric c. Organelles c. Compton d. DNA strands d. Bremsstrahlung 52. Long-wavelength x-rays are removed from the pri- 61. When a quality control test for exposure linearity mary beam by the use of a is performed, adjacent mA stations must be within a. Collimator ______of one another. b. Filter a. 2% of SID c. Cylinder cone b. 4% d. Gonadal shield c. 10% 53. The primary purpose of radiation safety practices is to d. 5% a. Limit occupational exposure 62. When a quality control test for exposure reproduc- b. Limit the introduction of mutations into the pop- ibility is performed, successive exposures must be ulation within ______of one another. c. Limit long-term somatic effects a. 2% of SID d. Limit short-term somatic effects b. 4% c. 10% Image Production (Questions 54-103) d. 5% 54. Devices in the x-ray circuit that increase or decrease 63. When a quality control test for collimator accuracy is voltage are called: performed, the result must be within ______. a. Rectifiers a. 2% of SID b. Generators b. 4% c. Timers c. 10% d. Transformers d. 5% CHAPTER 6 Challenge Tests 187

64. When a quality control test for accuracy of kVp is 73. Manual manipulation of the digital image after acqui- performed, the result must be within ______of sition is referred to as: the control panel setting. a. Digital coding a. 2% of SID b. Postprocessing b. 4% c. Leveling c. 10% d. Archiving d. 4 74. As speed class decreases, patient dose: 65. The accuracy of collimation at a 72-inch SID must be: a. Increases a. ± 1.44 inches b. Decreases b. ± 7.2 inches c. Remains the same c. ± 3.6 inches 75. Because the digital system software ultimately con- d. ± 0.02 inch trols contrast, kVp may be: 66. The feature of the image intensifier that ensures the a. Increased radiation dose striking the input phosphor is constant b. Decreased is the: c. Kept the same a. Photocathode 76. Image acquisition, image display, and image storage b. Electron focusing lens are the primary components of what system? c. Automatic brightness control a. DICOM d. Vidicon tube b. CR/DR 67. Instead of Vidicon or Plumbicon tubes, what device c. PACS may be used in the television system? d. HIS a. Charge-coupled device (CCD) 77. What “language” is used by PACS? b. C-arm a. DICOM c. Automatic brightness control b. Base 10 d. Output phosphor c. HIS 68. The electronic device that may be used for many qual- d. RIS ity control tests on x-ray equipment is the: 78. Which exposure factor causes excessive image noise if a. Automatic exposure control set too high? b. Digital dosimeter a. kVp c. Penetrometer b. mAs d. Densitometer c. AEC 69. The smallest particle of a compound that retains the d. Time characteristics of the compound is a(n): 79. Which of the following can be documented as an a. Element indication of patient dose? b. Atom a. AEC c. Molecule b. Exposure indicator d. Neutron c. System speed class 70. Given an original technique of 20 mAs and 80 kVp, d. Histogram which of the following would produce a radiograph 80. Choosing the anatomic region on a touch screen dis- with double the IR exposure? play to set technique is called: a. 40 mAs, 90 kVp a. Phototiming b. 30 mAs, 92 kVp b. Anatomically programmed radiography c. 40 mAs, 80 kVp c. AEC imaging d. 15 mAs, 92 kVp d. Automatic radiography 71. Distance and density are governed by what law or 81. What is used to reduce both patient dose and the pro- rule? duction of scatter radiation? a. Reciprocity law a. Grids b. 15% rule b. High speed class c. Inverse square law c. Collimation d. Density maintenance rule d. Filtration 72. Unwanted markings on a radiographic image are 82. Image artifacts are usually classified as: called: a. Scatter a. Processing irregularities b. Plus or minus density b. Processing artifacts c. Compton and photoelectric c. Artifacts d. Patient motion and equipment motion d. Plus-density markings 188 PART 1 Review and Study Guide

83. Grid ratio is expressed as: c. Speed a. Length of the lead strips to the space between them d. Contrast improvement factor b. Height of the aluminum strips to the space 93. Which of the following grid errors would result in an between them image that shows normal exposure in the middle but c. Height of the interspacers to the lead strips decreased exposure on the sides, assuming the correct d. Height of the lead strips to the space between them side of the grid faces the x-ray tube? 84. The primary type of grid used in diagnostic imaging is: a. Upside down a. Crosshatch b. Off-level b. Parallel c. Lateral decentering c. Rhombic d. Grid-focus decentering d. Focused 94. Which of the following grid errors would result in an 85. Which of the following does not belong in the defini- image that shows decreased density more to one side tion of matter? than the other? a. Travels at the speed of light a. Upside down b. Has shape b. Off-level c. Has form c. Lateral decentering d. Occupies space d. Grid-focus decentering 86. The accuracy of collimation at a 60-inch SID must be: 95. Grid ratio is described by which of the following? a. ± 6 inches a. H & D b. ± 3 inches b. H/D c. ± 2 inches c. mAs = mAs d. ± 1.2 inches d. 15% rule 87. Which of the following is true regarding frequency 96. Grid radius is described as: and wavelength of electromagnetic radiation? a. The height of the lead strips divided by the dis- a. Frequency and wavelength are directly proportional tance between the lead strips b. Frequency and wavelength are unrelated b. The distance between the lead strips divided by the c. Wavelength and frequency are inversely proportional height of the lead strips to the square of the distance between wave crests c. The number of lead strips per inch or centimeter d. Wavelength and frequency are inversely propor- d. The SID at which the grid may be used tional 97. Structures seen outside of the collimated area on a 88. Beam restrictors reduce the amount of scatter pro- radiograph, produced by “off-focus” (extrafocal) radi- duced by reducing which of the following? ation, are the result of: a. Characteristic rays a. Electron interaction within the x-ray tube at a b. Photoelectric effect point other than the focal spot c. Compton interactions b. Scatter radiation emanating from the patient or d. Pair production tabletop 89. What effect does increasing filtration have on con- c. The use of an SID that is not recommended with trast? the grid in use a. Increases contrast d. The x-ray tube positioned off-center to the grid b. Decreases contrast 98. Geometric unsharpness within the radiographic c. No effect image can be minimized by using the: d. Varying effect 1. Smallest focal spot 90. Decreased SID causes image: 2. Shortest object-image receptor distance a. Minification 3. Longest target-image receptor distance b. Foreshortening a. 1 and 2 only c. Elongation b. 1 and 3 only d. Magnification c. 2 and 3 only 91. Inaccurate use of grids may result in repeat exposures d. 1, 2, and 3 due to what condition? 99. An undistorted radiographic image results when the a. Overexposure object plane and the image plane are: b. Grid analysis error a. Angled in relation to each other c. Underexposure b. At right angles d. Cut-off c. Parallel 92. The measure of a grid’s ability to enhance contrast is d. Perpendicular called: a. Grid ratio b. Grid selectivity CHAPTER 6 Challenge Tests 189

100. A radiographic grid should be used when: c. Sulcus 1. The body area to be radiographed measures d. Sinus more than 10 cm 109. A “typical” skull would be described as: 2. A field size larger than 10 to 12 inches is used a. Synarthroses 3. More than 60 kVp is required to penetrate a b. Amphiarthroses body part c. Diarthroses a. 1 and 2 only d. Mesocephalic b. 1 and 3 only 110. Synovial joints are called: c. 2 and 3 only a. Synarthroses d. 1, 2, and 3 b. Amphiarthroses 101. Twice as many electrons strike the target in the x-ray c. Diarthroses tube when: d. Mesocephalic a. kVp is doubled 111. Fibrous joints are called: b. mAs is doubled a. Synarthroses c. SID is reduced by one-half b. Amphiarthroses d. OFD is reduced by one-half c. Diarthroses 102. How does beam restriction affect contrast? d. Mesocephalic a. Decreases contrast 112. The radiocarpal joint has what type of movement? b. Longer scale of contrast a. Hinge c. Shorter scale of contrast b. Pivot d. No effect on contrast c. Saddle 103. Grid conversion factor (Bucky factor) is described as the: d. Condyloid a. Height of the lead strips divided by the distance 113. The proximal radioulnar articulation has what type of between the lead strips movement? b. Distance between the lead strips divided by the a. Hinge height of the lead strips b. Pivot c. Number of lead strips per inch or centimeter c. Saddle d. Amount of exposure increase necessary to com- d. Gliding pensate for the absorption of image-forming rays 114. Which of the following bones has a temporal process? and scatter in the cleanup process a. Sphenoid bone b. Ethmoid bone Procedures (Questions 104-167) c. Mandible For the following questions, choose the single best answer. d. Zygomatic bone 104. An enlargement at the end of a bone is called a: 115. Which of the following bones has an alveolar process? a. Prominence a. Sphenoid bone b. Sharp prominence b. Ethmoid bone c. Tubercle c. Mandible d. Head d. Maxilla 105. A rounded projection of moderate size is called a: 116. Which of the following bones has wings? a. Prominence a. Sphenoid bone b. Sharp prominence b. Ethmoid bone c. Tubercle c. Mandible d. Tuberosity d. Maxilla 106. A spine describes a: 117. Which of the following bones has a coronal suture? a. Prominence a. Frontal bone b. Sharp prominence b. Temporal bone c. Tubercle c. Occipital bone d. Tuberosity d. Parietal bone 107. A pit is described as a: 118. Which of the following bones has an external protu- a. Fossa berance? b. Groove a. Frontal bone c. Sulcus b. Temporal bone d. Sinus c. Occipital bone 108. A furrow is described as a: d. Mandible a. Fossa b. Groove 190 PART 1 Review and Study Guide

119. Which of the following bones consists of five fused 129. Which bone distributes body weight from the tibia to segments? the other tarsal bones? a. Sacrum a. Navicular b. Axis b. Calcaneus c. Thoracic vertebra c. Talus d. Lumbar vertebra d. Cuboid 120. Which of the following bones has a dens? 130. Which bone lies along the lateral border of the navic- a. Atlas ular bone? b. Axis a. Navicular c. Thoracic vertebra b. Calcaneus d. Lumbar vertebra c. Talus 121. Which of the following individual vertebra is larger d. Cuboid and heavier than other individual vertebrae? 131. Which of the following articulate(s) with the first, a. Atlas second, and third metatarsal bones? b. Axis a. Navicular c. Thoracic vertebra b. Calcaneus d. Lumbar vertebra c. Talus 122. The eleventh and twelfth pairs of ribs are called: d. Cuneiforms a. Manubrium 132. This structure has superior, middle, and inferior lobes: b. Floating a. Trachea c. Xiphoid b. Left lung d. Jugular notch c. Right lung 123. The blunt cartilaginous tip of the sternum is the: d. Hilus a. Manubrium 133. This structure is approximately 12 cm long and is b. Floating located in front of the esophagus: c. Xiphoid a. Trachea d. Jugular notch b. Left lung 124. Located between the greater and lesser tubercles of c. Right lung the humerus is (are) the: d. Hilus a. Greater and lesser tubercles 134. The narrow distal end of the stomach that connects b. Bicipital groove with the small intestine is called the: c. Capitulum a. Rugae d. Trochlea b. Pylorus 125. Located below the tubercles of the humerus is (are) c. Fundus the: d. Greater curvature a. Greater and lesser tubercles 135. The section of the stomach where the esophagus b. Bicipital groove enters is called the: c. Capitulum a. Rugae d. Surgical neck b. Pylorus 126. Which of the following part(s) of the humerus c. Fundus articulate(s) with the ulna? d. Cardiac portion a. Greater and lesser tubercles 136. The lateral surface of the stomach is called the: b. Bicipital groove a. Rugae c. Capitulum b. Pylorus d. Trochlea c. Fundus 127. Which bone is located in the wrist, between the trap- d. Greater curvature ezoid and the hamate? 137. The portion of the colon located between the splenic a. Scaphoid flexure and the sigmoid portion is called the: b. Hamate a. Duodenum c. Pisiform b. Descending d. Capitate c. Ileum 128. Which bone is located in the wrist, between the d. Ascending lunate and the pisiform? a. Scaphoid b. Hamate c. Pisiform d. Triquetrum CHAPTER 6 Challenge Tests 191

138. The portion of the small bowel that connects with the 147. For AP projection of the foot, the central ray enters at cecum is called the: the: a. Duodenum a. Head of the third metatarsal b. Jejunum b. Head of the second metatarsal c. Ileum c. Base of the first metatarsal d. Ascending d. Base of the third metatarsal 139. The portion of the small bowel that connects with the 148. For axial projection of the calcaneus, the central ray is stomach is called the: angled how many degrees to the long axis of the foot? a. Duodenum a. 25 b. Jejunum b. 15 c. Ileum c. 10 d. Ascending d. 40 140. The outer part of the kidney is called the: 149. For AP projection of the ankle, the central ray is a. Cortex directed perpendicular to the: b. Medulla a. Lateral malleolus c. Nephron b. Ankle joint midway between malleoli d. Glomeruli c. Medial malleolus 141. The part of the kidney through which blood is first d. Tibia filtered is called the: 150. For AP projection of the knee, the central ray is a. Cortex angled: b. Medulla a. 5 to 7 degrees cephalad c. Nephron b. 5 to 7 degrees caudad d. Glomeruli c. 10 degrees cephalad 142. For radiography of the fingers, the central ray enters: d. 10 degrees caudad a. Perpendicular to the distal interphalangeal joint 151. For AP projection of the cervical spine, the central ray b. Parallel to the distal interphalangeal joint is directed: c. Parallel to the proximal interphalangeal joint a. 10 degrees cephalad d. Perpendicular to the proximal interphalangeal joint b. Parallel to C4 143. For a PA projection of the hand, the central ray is c. 15 to 20 degrees caudad centered: d. 15 to 20 degrees cephalad a. Perpendicular to the first metacarpophalangeal joint 152. For lateral projection of the cervical spine, the central b. Perpendicular to the third metatarsophalangeal ray is directed: joint a. Perpendicular to C4 c. Parallel to the third metacarpophalangeal joint b. Parallel to C4 d. Perpendicular to the third metacarpophalangeal c. 15 to 20 degrees caudad joint d. 20 to 25 degrees cephalad 144. For a lateral projection of the wrist, the elbow must be 153. For AP projection of the thoracic spine, the central flexed: ray is directed: a. 45 degrees a. 5 degrees cephalad b. 90 degrees b. Parallel to T7 c. Only slightly c. 3 to 4 degrees caudad d. Approximately 25 degrees d. Perpendicular to T7 145. For PA axial projection of the clavicle, the central ray 154. For AP projection of the lumbar spine, the central ray is angled: is directed: a. 25 to 30 degrees caudad a. Parallel to midline, entering at the level of the iliac b. 25 to 30 degrees cephalad crests c. 20 degrees caudad b. Perpendicular to L2 d. 20 degrees cephalad c. Perpendicular to midline, entering at the level of 146. For AP projection of the toes, the central ray enters at the iliac crests the: d. Perpendicular to L4 a. Third metatarsophalangeal joint 155. For AP oblique projections of the sacroiliac joints, the b. Second metacarpophalangeal joint central ray is directed: c. First metatarsophalangeal joint a. 1 inch lateral to elevated ASIS d. Second metatarsophalangeal joint b. 1 inch medial to elevated ASIS c. 1 inch lateral to dependent ASIS d. 1 inch medial to dependent ASIS 192 PART 1 Review and Study Guide

156. For PA projection of the chest, the central ray is directed: 166. The ilium is part of the: a. Perpendicular to T10 a. Hip b. Parallel to the thoracic spine b. Shoulder c. Perpendicular to T7 c. Skull d. Perpendicular to the posterior ribs d. Small intestine 157. For AP projection of the lower ribs, the central ray is 167. An AP lordotic chest radiograph best demonstrates directed: the: a. Perpendicular to T10 a. Apices of the lungs b. Perpendicular to T5 b. Bases of the lungs c. Perpendicular to T7 c. Mediastinal structures d. Perpendicular to T12 d. Position of the diaphragm 158. For AP axial (Towne) projection for the skull, the central ray is directed: Patient Care (Questions 168-200) a. 30 degrees to IOML 168. The major advantage of nonionic contrast media over b. 37 degrees to OML ionic contrast media is that nonionic contrast agents: c. 25 degrees to IOML a. Are considerably less expensive d. 30 degrees to OML b. Are less likely to cause an adverse reaction in the 159. For lateral projection of the facial bones, the central patient ray enters at the: c. Provide better radiographic contrast a. Glabella d. Require the use of considerably less kV and mAs b. Medial surface of the zygomatic bone 169. Which of the following should be used when a person c. Medial surface of the nasal bone is choking on a piece of food? d. Lateral surface of the zygomatic bone a. Heimlich maneuver 160. An imaging exam using a contrast agent to visualize b. Modified Valsalva maneuver the uterus and fallopian tubes is called a(n): c. Valsalva maneuver a. Uterogram d. Toe touch maneuver b. Hysterosalpingogram 170. During an injection of contrast media, extravasation c. Intravenous urogram occurs. The proper procedure is to: d. Pregnancy study a. Continue the injection and tell the patient the 161. An imaging exam using a contrast agent to evaluate burning sensation will subside momentarily possible herniated intervertebral discs is called a(n): b. Remove the needle and hold pressure on the vein a. Arthrogram until all bleeding has stopped b. Spinal study c. Remove the needle, repuncture the same vein, and c. Myelogram continue the injection d. Discography d. Place a warm compress above the site of injection 162. An exam that may be diagnostic and therapeutic is: and continue administering the contrast a. Hysterosalpingogram 171. What must precede any examinations involving b. Myelogram iodinated contrast media? c. Arthrogram a. Chest x-ray study d. Barium enema b. Nephrotoxicity assessment 163. The injection site for a lumbar myelogram is: c. Patient held NPO a. C6-C7 d. Pregnancy test b. L5-S1 172. Diabetic patients should be scheduled: c. L3-L4 a. Later because of their need for insulin d. L1-L2 b. Early because of their need for insulin 164. An imaging exam using a contrast agent to visualize c. Just before mealtime possible meniscal tears is called a(n): d. Just after mealtime a. Myelogram 173. The pelvocalyceal system reaches greatest visualization b. Arthrogram approximately how many minutes after injection? c. Joint manipulation study a. 1 to 2 d. Sports injury exam b. 2 to 5 165. Arthrography is increasingly being replaced by what c. 2 to 8 imaging modality? d. 15 to 20 a. CT b. Diagnostic ultrasound c. PET scanning d. MRI CHAPTER 6 Challenge Tests 193

174. The ARRT Rules of Ethics and Code of Ethics are 184. This item is used to restore the heart to normal contained in what document? rhythm: a. Standards of Ethics a. Crash cart b. Practice Standards b. Suction unit c. Mission Statement c. Defibrillator d. Scope of Practice d. Sphygmomanometer 175. Violations of civil law are known as: 185. A type of shock that is caused by a severe allergic reac- a. Assault tion is called: b. Battery a. Hypovolemic shock c. False imprisonment b. Septic shock d. Torts c. Neurogenic shock 176. Unjustified restraint of a patient defines: d. Anaphylactic shock a. Assault 186. An item that is used to feed the patient or to suction b. Battery gastric contents is a: c. False imprisonment a. Ventilator d. Invasion of privacy b. Nasogastric tube 177. The suffix that means “like” is: c. Chest tube a. -oma d. Venous catheter b. -oid 187. An item that must never be placed above the level of c. -osis the bladder is a: d. -pathy a. Ventilator 178. The suffix that means “tumor” is: b. Nasogastric tube a. -oid c. Chest tube b. -pathy d. Urinary catheter c. -oma 188. A mechanical respirator is called a: d. -algia a. Ventilator 179. A legal doctrine that states that the cause of the negli- b. Nasogastric tube gence is obvious is known as: c. Chest tube a. Respondeat superior d. Venous catheter b. Res ipsa loquitur 189. Barium sulfate should be mixed with water at what c. Gross negligence temperature for a barium enema? d. Slander a. 100° C 180. Tachycardia indicates a pulse of: b. 75° F a. Greater than 100 beats per minute c. 85° C b. Less than 60 beats per minute d. 100° F c. Greater than 90 beats per minute 190. A positive contrast agent administered to a patient in d. Less than 50 beats per minute the form of an inert salt is: 181. Some level of hypertension is indicated when diastolic a. Barium sulfate pressure is: b. Iodine a. Greater than 100 mm Hg c. Perforated ulcers or ruptured appendix b. Less than 60 mm Hg d. Air c. Greater than 90 mm Hg 191. The most effective method to prevent the spread of d. Less than 50 mm Hg infection is: 182. When oxygen is administered to the patient, the usual a. Use of gloves flow rate is: b. Use of gowns a. 3 to 5 L/second c. Time, distance, and shielding b. 5 L/hour d. Handwashing c. 1 to 3 L/minute 192. If you suspect an object is contaminated, assume: d. 3 to 5 L/minute a. That it is contaminated 183. This item is used to clear an obstructed airway: b. That it should be used immediately a. Crash cart c. That it is not contaminated, so as not to waste sup- b. Suction unit plies c. Defibrillator d. That your hands must be sterilized d. Sphygmomanometer 194 PART 1 Review and Study Guide

193. Factors that may cause the patient to react to a con- 198. The complete removal of all organisms from equip- trast agent simply as a result of anxiety are termed: ment and the environment in which patient care is a. Local irritation conducted is called: b. Cardiovascular a. Medical asepsis c. Anaphylactic b. Surgical asepsis d. Psychogenic c. Standard precautions 194. A reaction that may occur in the vein in which an d. Gas sterilization injection occurred is: 199. The word part that means “organ” is: a. Local irritation a. Viscer b. Cardiovascular b. Megal c. Anaphylactic c. Trans d. Phlebitis d. Emia 195. This type of infection transmission occurs when an 200. The word part that means “kidney” is: animal contains and transmits an infectious organism a. Viscer to humans: b. Megal a. Contact transmission c. Trans b. Airborne transmission d. Nephr c. Droplet transmission d. Vectorborne transmission Scoring 196. This type of infection transmission occurs as a result Traditionally you have probably focused on how many ques- of coughing or sneezing: tions you miss on a test. As you prepare for the certification a. Contact transmission exam, I encourage you to focus on how many you answer b. Airborne transmission correctly. Use Table 6-3 to calculate the percentage of ques- c. Droplet transmission tions you answered correctly in each category and on the d. Common vehicle transmission test as a whole. Remember, a score of less than 75% on any 197. This type of infection transmission occurs when an topic or the entire test is an indication that more review infected person or contaminated object touches a host: is needed on that topic. Now go back and concentrate on a. Contact transmission which items were missed and the reason why. When you are b. Airborne transmission done reviewing, go on to the tutorials and tests found on the c. Droplet transmission Evolve web site. d. Common vehicle transmission

TABLE 6-3 Calculating Your Score for Challenge Test Number 3 Topic Percentage Calculation Your Score

Safety Number correct ______× 100, ÷ 53 = Image Production Number correct ______× 100, ÷ 50 = Procedures Number correct ______× 100, ÷ 64 = Patient Care Number correct ______× 100, ÷ 33 =

Total Number correct ______× 100, ÷ 200 = PART II

Career Planning

195 7 Career Paths

Career Planning Inventory to you. If so, your goals may include completing advanced Individuals pursue chosen careers for a variety of reasons. academic degrees and finding a clinical job in a teaching Their sources of motivation for enrolling in an educational institution. program and satisfying all of the graduation requirements Take time now to answer questions 1 and 2 in the space may include the need for a stable income, the desire to provided. Remember, you are examining situations you find become established in a career, or an interest in expanding motivating and exciting. You will have an opportunity to set their horizons. Incentives for undertaking such a process your goals later in this chapter. are unique to each individual and may clearly distinguish I am really excited about: a 45-year-old from an 18-year-old. Also, incentives can ______change as you move toward a goal, so the circumstances that ______led you to select this educational program may differ con- ______siderably from circumstances that influence you to establish ______a career in this field. Whether you are reading this chapter as a new radiogra- The aspects of patient care that have been most satisfying phy student, during your final year, or in your final semes- are: ter, it is a good idea to examine your motivation for seeking ______employment and establishing a career in radiologic technol- ______ogy. You should reexamine your motivation and adjust your ______goals regularly—perhaps annually. The following questions can help with that process and assist you in establishing 3. Of the people with whom I have worked in clinical career goals. education, who has been most helpful? 1. Based on my studies and clinical education so far, 4. Which characteristics do I want to emulate most? what aspects of this profession am I really excited Rationale: As a radiography student, you may be about? profoundly influenced by the personnel in the clinical 2. Which aspects of patient care have I found the most department. It is important to identify people who have satisfying? been particularly helpful to you as you have acquired Rationale: Questions 1 and 2 attempt to help you focus your clinical skills. It is often tempting to think about, on what has brought you true satisfaction so far in the edu- talk about, and remember only the people who have cational program. Being excited about what you do is criti- been hindrances to your education or who simply did cal to your longevity in the field. It is a daily reinforcement not enjoy working with students. Concentrate instead to your motivation. It helps you bring a positive attitude to on the positive people, and prepare a list of their names. class and to the clinical environment. Many individuals find Describe the personal and professional characteristics certain aspects of patient care particularly satisfying. Identi- they possess. Explain why you enjoy working with them. fying yours can help you set goals for job placement or for Everyone benefits from role models. Describe why you continuing your education. For example, if you find great wish to emulate, or pattern your professional attitudes satisfaction working with children, pediatric radiography and demeanor after, certain people with whom you have may be an excellent choice for a career. You could consider worked. job possibilities at children’s hospitals. Perhaps trauma radi- The most helpful individuals in clinical education have ography is particularly challenging and satisfying for you. been: Pursuing employment at an institution with a trauma center ______and a shift with a high level of trauma cases would be a wise ______choice. Maybe teaching and working with students appeals ______

196 CHAPTER 7 Career Paths 197

They have been great to work with because: With a fluctuating job market, you must consider whether ______you will remain rooted where you are or relocate to find the ______type of position you desire. Perhaps relocating is something ______you have wanted to do all along or maybe relocating is simply not possible at this point in your life. I will emulate the following positive behaviors (also explain Answer each question in the space that follows. Describe why): what your needs and wants will be after graduation. ______Employment: ______5. When during the educational process have I been Financial: most satisfied? ______6. When during the educational process have I been ______least satisfied? ______Rationale: An awareness of events, people, or situations Housing: that have caused you to feel happy or unhappy can be help- ______ful in setting goals for employment. It is impossible to be ______satisfied or happy on the job all of the time or to avoid all ______unpleasant situations; however, being aware of such times Location: can help you decide where you may or may not wish to ______work. In addition, addressing these issues now can help you ______understand how you respond to positive and negative situa- ______tions and how to alter your responses if necessary. You may also wish to consider ways to maintain a positive outlook Use the financial planning worksheet shown in Figure 7-1 when dealing with unpleasant situations or individuals by to determine your actual salary needs. Be sure to base your recalling successful, self-motivating strategies from the past. compensation needs on your individual obligations, regard- The mark of a true professional is the ability to summon the less of any domestic relationship that may include a combi- highest level of performance from yourself and the people nation of incomes. around you even during difficult times. 11. Am I more excited about working with the high- I have been most satisfied during my education when: touch (people-oriented) aspects of this profession ______or the high-tech (equipment) aspects of the field? ______Rationale: Some individuals work in this field because ______they truly love working with people and assisting with the diagnosis of their conditions. Others prefer working with I have been most dissatisfied during my education when: complex electronic and computerized equipment and ______would rather not be involved in direct patient care. There ______is room for both types of people in this profession and for ______people who truly enjoy blending high touch with high tech. Identifying the aspects of the field that excite you can help 7. What employment needs will I have after graduation? with your career planning. 8. What financial needs will I have after graduation? Perhaps you wish to continue providing direct patient 9. What housing needs and living conditions will I seek care. Maybe you would rather work in areas involving after graduation? significant use of equipment, such as in quality control, 10. Do I want or need to stay in this geographic area, or medical physics, or the sale and service of equipment. You do I want or need to relocate? may also serve patients indirectly in a position such as Rationale: Individuals often do little or no planning for PACS administrator. Nothing will cause you to become their employment, financial needs, or living conditions. more dissatisfied with your career choice than working Consider what your needs will be for employment when in an area of radiologic technology to which you are not you graduate. Decide whether you will need to begin work suited. Develop awareness now of what you most enjoy immediately and have to accept the first job offer you receive doing. There is no right or wrong answer, and your choice or whether you can wait a short time to scout the job market does not make you “good” or “bad.” Most important, be more thoroughly. It is crucial to have some idea of what honest with yourself. You will have much to contribute your financial needs will be. Be aware of the cost of setting to this field if you work where you are happiest and most up your own living arrangements, paying back school loans, productive. or providing for your family. If you are not currently respon- Take some time and write in the space that follows sible for your own housing, decide how it will be arranged. your honest preferences based on your experiences so far. 198 PART 2 Career Planning

Annual Living Expenses These are for the entire year; be sure to calculate annual figures.

Federal income tax (annual salary ϫ %) $ Social Security tax (annual salary ϫ 7.65%) State income tax (annual salary ϫ %) Medicare tax (annual salary ϫ %) Savings Health insurance Rent or house payment Renter or homeowner insurance Child care College loan repayment Electricity Water Gas Cable/satellite services Cellular phone service Internet service provider Food (excluding eating out) Car payment Car insurance Car operation (gasoline, oil changes, etc.) Clothing Entertainment (night out, movie rentals, music, etc.) Gifts (for birthdays, holidays, weddings, anniversaries, etc.) Donations (place of worship, charities, etc.) Debt, credit card payments Other: Other:

Total annual estimated living expenses ϭ $

I will need the following annual salary to meet these expenses: $ I will need the following hourly salary to meet these expenses: $ (divide annual salary needed by 2080 hours to determine hourly salary needed)

This form is not meant to be a substitute for guidance provided by a financial counselor or tax advisor. Scholarships are not included in salary because they are one-time payments, not hourly salary. Taxes could be reduced with personal exemptions, deductions, credits, etc. Consider these factors when calculating actual tax liability.

• Figure 7-1 Annual living expenses.

Remember, you are not setting a goal at this point, and your time you graduate. Be aware you will need to set a course answer may change over time. for lifelong learning. Understanding this reality now can High tech versus high touch—my preference and why: assist you in developing your professional attitude and plan- ______ning for continuing education. Realizing the importance of ______a commitment to learning may also serve to motivate you ______through the remainder of your educational program. Take time to assess your motivation for learning. In the 12. Do I enjoy learning all I can about this field, or do space that follows, describe your honest feelings and atti- I want to learn only what I need to graduate? tudes about the enjoyment of learning for its own sake as opposed to learning just enough to perform your job. Rationale: Your answer to this question is very important. I want to learn all I can or just enough to get by. Here are The field you have chosen changes rapidly. You must be hon- my reasons and motivations: est with yourself about your desire to study and learn. The ______equipment currently used in clinical education did not even ______exist a few years ago. You will use equipment a few years ______after you graduate that does not exist today. If you are con- ______tent to learn only what you need to graduate, you will soon possess outdated skills. You should also consider whether 13. Which aspect(s) of the specialty of radiography do you truly enjoy learning or tend to regard it as a burden. I enjoy the most (e.g., general, fluoroscopy, mobile, Your education in this field will have barely begun by the surgical, trauma, pediatric)? CHAPTER 7 Career Paths 199

14. Have I particularly enjoyed any other radiologic attending their first meeting, serving on a committee for the specialties (e.g., angiography, mammography, CT, first time, or holding their first office. Think about how such MRI, sonography, nuclear medicine, fusion imag- involvement may add to your career and personal satisfaction. ing, radiation therapy, quality control)? In the space provided, write your thoughts and feelings Rationale: You may not yet realize radiography is a spe- about pursuing these activities. Describe how you would cialty within which are areas of further specialization (e.g., feel if you became involved at this level of the profession. general, fluoroscopy, mobile, informatics). You are probably The special projects that brought me the most satisfaction already familiar with the other specialties listed in question were: 14. By being aware of what you enjoy, you will have little ______difficulty later setting goals for employment or education. If ______you have not yet had the opportunity to spend clinical time ______in some of the areas mentioned, you may need to postpone answering this question. However, when such an opportu- I wish to become involved in the following organization(s) nity arises, prepare yourself for the clinical experience by in this capacity: reading about the specialty area in your textbook and taking ______careful notes about your experiences. This field has count- ______less opportunities for you in the practice of radiography or ______any of the other special imaging or therapy modalities. Use the space provided to list the areas in which you are 17. Do I believe I will have an interest in working with particularly interested, and describe why you have enjoyed students when I am employed? them. Also list the areas you look forward to exploring, and Rationale: You will need to assess your interest in work- explain why they are important to you. ing with students. Many of us truly enjoy helping students I particularly enjoy working in the following area(s): acquire skills, whereas some would prefer to avoid educat- ______ing others. If you believe you would enjoy teaching, seeking ______employment in an academic environment is a reasonable ______goal. If you would prefer not to work with students, it would be better for you and for the students if you seek I want to explore the following areas further: employment in another setting. Many otherwise excellent ______radiographers find frustration on the job because they are ______not suited to the clinical teaching role. Do not take this ______issue lightly. Having a student assigned to you every day of work can be exhilarating or burdensome, depending on 15. Are there any special projects I have done that your professional preferences. brought me satisfaction (e.g., research papers, In the space provided, state whether you prefer to work exhibits, in-class presentations, participation in with students or to find employment in a nonteaching radiography scholar bowls)? institution. 16. Am I interested in pursuing positions of leadership I would or would not like to work with students after gradu- or membership in local, state, or national radio- ation. Here are my reasons: logic technology organizations? ______Rationale: This profession needs you. It needs what you ______have to offer. It needs your fresh ideas and observations. It ______needs your leadership, motivation, talents, and abilities. By considering the issues mentioned in questions 15 and 16, 18. In what type of clinical setting am I most comfort- you can set goals for your postgraduation involvement. able (e.g., hospital, small clinic, physician’s office, Perhaps you have already written a research paper, con- urgent care)? structed an exhibit, or participated in a scholar bowl compe- Rationale: Health care assumes many forms, depending tition. Do not stop now. You have momentum working in in part on the environment in which it is delivered. If you your favor. Consider how these projects may have brought have had the opportunity to spend clinical time in more you satisfaction and served to motivate you further. Think than one of the settings mentioned, decide which you about how you may set goals for doing additional proj- enjoyed most. If you have not had this opportunity, check ects or presentations as a radiographer for state or national with your program director about the availability of clini- presentations. cal rotations. If none are available in the program, consider Local, state, and national professional organizations in spending time outside of school in one or more of these radiologic technology need the involvement of motivated, clinical settings to get some idea of how they operate and to committed professionals. Gauge your interest in becoming observe the radiographer at work. involved. Do not let fear of the unknown deter you. Remem- Each clinical setting has qualities that may appeal to you ber, individuals who are currently active were at one time as a radiographer and others that may make it a less attractive 200 PART 2 Career Planning

choice. You may also be guided by a strong personal prefer- • Assess your interest in working with students and seek ence about where you would like to work. Consider these employment accordingly. factors carefully when setting goals for employment. • Consider the numerous venues in which you may I have had experience in the following clinical settings. Here practice radiography, such as hospitals, clinics, is what I liked and disliked: physician offices, and prompt care sites. • Identify the talents you have to offer a potential ______employer and how you may use these talents to pursue ______your personal and professional goals. ______• Examine how your strengths may benefit the patients ______you serve and how they may have a positive impact on your coworkers. 19. What particular talents do I possess about which I feel proud? Rationale: Identify your talents and all you have to offer Goal Setting a potential employer. Consider how you may use these talents to pursue your personal and professional goals. Think By carefully answering the previous questions, you should of how your strengths may benefit the patients you serve. develop a good idea of the things that motivate you in this Understand the impact you may have on coworkers. It is field. The choice of a career is important, and you should be important to be proud of your talents and use them. It is not intent on doing the things you particularly enjoy. conceited to list them. You must concentrate on being the Individuals who have been successful in the field of radio- best you can be by developing your abilities and acquiring logic technology have set goals for themselves and worked others. Use them to enhance your practice of radiography hard to achieve them. Goal setting is not an easy task, par- and your personal life. ticularly because it is seldom taught in school. However, all My particular talents and positive attributes follow. Here is of the great motivational speakers and career planners indi- how I have used them and why I am excited about them: cate that goal setting should be a priority, not only when ______beginning a career, but throughout your working lifetime. ______Goals are not meant to be etched in granite and never ______changed or updated. Goal statements should be flexible and ______fluid. They should be realistic, measurable, and achievable. If you are the type of person who needs to see immediate or short-term progress, break down your goals into smaller KEY POINTS events. Approach these goals incrementally and celebrate Career Planning Inventory each achievement. As mentioned previously, goals should be updated as needed and at least annually. • Examine your motivation for seeking employment and The wording of goal statements can be as important as establishing a career in radiologic technology. setting the goals themselves. Statements such as “I want to • Adjust your goals regularly. be a nuclear medicine technologist within 3 years” are not • Being passionate about what you do is key to your longevity in the field. powerful enough. “I will be a registered nuclear medicine • Identify people who have been particularly helpful to technologist by the end of (specify year)” is more specific. you in clinical education. It is action oriented. It says you will do something, and you • Concentrate on positive people who enjoy working with will direct your energies toward achieving that goal within a patients and students. specific time frame. It is more than a wish; it is a statement • A true professional has the ability to summon the highest level of performance even during difficult times. of a goal that you expect to realize. • Consider what your needs will be for employment when Post your goals where you can see them daily, and share you graduate. them with the people who are significant in your life. • It is important to ascertain your financial needs. Encouragement and moral support of loved ones can help • Determine whether you will remain where you are or if you achieve your goals. Shared goals are more likely to be you wish to, or will need to, relocate. • Balancing high tech with high touch is key to quality met because of the increased sense of accountability to oth- patient care. Knowing your preference leads to your ers who are aware of them. success. The following is a series of questions to consider as you • A thorough understanding of options in radiologic write your goal statements. Sample goal statements are pro- technology can assist with career goals. vided. Note that they are specific, have time frames, and use • This profession needs your fresh ideas, observations, leadership, motivation, talents, and abilities. the words “I will.” You may be thinking that you lack some • Consider professional involvement such as presenting of the information needed to write your goal statements. at conferences, writing a research paper, constructing However, recognize that by writing goals and planning your a scientific exhibit, or holding office in a professional future, you are in the process of making that future a real- organization. ity. This helps you direct your energies toward pursuing and accomplishing your goals. CHAPTER 7 Career Paths 201

Setting goals should not be taken lightly, but it should GOAL: I am modifying my current study habits as follows: not be so arduous a task that it becomes a burden. Be excited ______about setting your goals and beginning to map out your future. Do not get discouraged if your goals seem simple at GOAL: I will begin my new study habits on ______. first. They are there to provide you with direction. It will be up to you to adjust them and to direct the course you plan 5. Do I need to examine my lifestyle choices regarding to follow. diet, exercise, and sleep requirements?

1. What deadline have I set for completion of my goal GOAL: I will evaluate my lifestyle choices in diet, exercise, statements? sleep, and recreation on ______.

GOAL: I will list my goals along with a timetable by the GOAL: I am modifying my diet as follows (be specific): following date: ______2. What kind of review schedule have I established to pre- ______pare for the radiography certification exam? GOAL: I am modifying my exercise routine as follows (be GOAL: I will review the subjects included on the exam specific): according to the following schedule: ______Patient Care: ______

Safety: GOAL: I am modifying my sleep routine as follows: ______Image Production: ______

Procedures: GOAL: I am taking time for recreation as follows: ______3. Do I want to pursue additional education in radiologic ______technology or seek an advanced degree? ______

GOAL: I will visit college or university websites to exam- 6. Have I taken into account the needs of my family or ine baccalaureate degree options by the following date: significant others? ______GOAL: I will consult with my significant others regarding GOAL: I will take ______number of credit hours per these goals on ______. semester beginning on ______so that I will complete my degree on ______. GOAL: I will list here the needs of my significant other(s) in view of the goals I have set: GOAL: I will visit websites regarding educational programs ______in ______(e.g., sonography, nuclear medicine, radi- ______ation therapy, CT, MRI) by ______. ______GOAL: I will attend an educational program in ______(e.g., sonography, nuclear medicine, radiation therapy, 7. What do I want to accomplish in the next 30, 60, and CT, MRI) beginning ______and will graduate from 90 days related to my career? the program in ______. GOAL: By 30 days from now, on ______, I will have 4. Do my regular study habits need to be examined and accomplished the following to advance my career goals: fine-tuned? ______GOAL: I will examine my current study habits on ______. ______202 PART 2 Career Planning

GOAL: By 60 days from now, on ______, I will have Local: accomplished the following to advance my career goals ______(built on my 30-day objectives): ______State: ______National: ______GOAL: By 90 days from now, on ______, I will have accomplished the following to advance my career goals 12. What other radiologic specialties should I explore? (built on my 30-day and 60-day objectives): ______GOAL: I will do extra reading and clinical observation ______in the following radiologic technology specialties (e.g., ______angiography, mammography, CT, MRI, sonography, ______nuclear medicine, radiation therapy, quality control) by the dates I have listed: 8. To reinforce my positive attitude, I will need to obtain ______access to motivational materials. ______GOAL: By ______, I will read the following motiva- ______tional books: ______13. I will pursue special projects after graduation. ______GOAL: I will write a research paper and submit it for com- ______petition at the state or national level on ______. The possible subjects for this paper are: 9. I must consider postgraduation needs. ______GOAL: I will begin work by ______. ______GOAL: I will make the following hourly salary to maintain ______the lifestyle I have chosen: ______GOAL: I will prepare a scientific exhibit for presentation at a state or national meeting on ______. The possible GOAL: I will live in the following type of housing: subjects for this exhibit are: ______GOAL: I will assist with planning the following local or GOAL: I will live in the following city or geographic state meeting: ______on ______. area: ______GOAL: I will run for the office of my local, state, or national professional organization on ______. 10. What are my preferences regarding high-tech versus high-touch aspects of radiography? 14. What is my attitude toward working with students?

GOAL: I will work in the following direct patient care area GOAL: I will work in a department that (is/is not) in a of medical radiography: teaching institution. ______15. I will explore different work settings. GOAL: I will work in the following patient care support area: GOAL: I will work in the following type of institution: hos- ______pital, clinic, imaging center, physician’s office, urgent care.

11. I need to consider continuing education in radiography. 16. What professional attributes do I consider important?

GOAL: I will follow this schedule for remaining current in GOAL: I will work to maintain the attributes that I admire my chosen field: most in the professionals who have helped me in my clinical education. Those attributes are: Type of meetings or conferences I will attend regularly: ______CHAPTER 7 Career Paths 203

______achieve. Performing this type of personal inventory has got- ______ten you off to a great start. In addition to reading your goal statements daily, reexamine these goals at regular intervals 17. What other goals will I set for myself? over the coming months. There will be no stopping you now!

GOAL: Continuing Education Requirements ______The quality of a person’s life is in direct proportion to their ______commitment to excellence regardless of their chosen field of ______endeavor. VINCE LOMBARDI GOAL: ______Meeting Professional and Governmental ______Requirements ______The purpose of certification is to assure the public that you are competent to practice in your chosen field. However, GOAL: passing a certification exam to enter the profession is no ______assurance that you will remain competent. It is of critical ______importance that you have the most current knowledge and ______skills needed to practice radiologic technology. ______Mandatory continuing education has been established in an attempt to ensure the continued competence of clini- GOAL: cians. Although research indicates that mandatory continu- ______ing education in any field of study is not a guarantee of ______competence, it is the route that has been chosen for many ______health professions, including radiologic technology, to ______maintain credibility with the public. After you successfully pass the certification exam and By now you have had considerable experience in describ- receive your initial registration, the American Registry of ing the aspects of this field that you find motivating. You have Radiologic Technologists (ARRT) requires documentation also listed specific career goals that you have the ability to of continuing education for you to renew your registration. Participating in continuing education and documenting your KEY POINTS participation are your responsibility as a registered technolo- Goal Setting gist. Although acquiring continuing education credits is not difficult for most technologists, knowledge of the applicable • A career choice is significant; focus on doing the things rules and regulations is of paramount importance. you particularly enjoy. In addition to certification, many states require indi- • Success in radiologic technology is based on setting viduals practicing medical radiography to hold licensure or goals and working hard to achieve them. accreditation issued by the state. Because legislation regulat- • Goal setting must be a priority throughout your working lifetime. ing state licensure may be subject to the addition or revision • Goals are not meant to be rigid and inflexible but alive of statutes at any time, the requirements specific to each and fluid. state are not listed here. Many states accept ARRT certifica- • Goals should be realistic, measurable, and achievable. tion as proof of the applicant’s competency. In those states, • Approach goals incrementally; celebrate each you need to apply to the appropriate agency, supply a copy achievement. • Goals should be updated as needed and examined at of your ARRT credentials, and pay the proper fee. Be sure least annually. to obtain the rules and regulations pertaining to licensure in • Make goal statements specific and action oriented. the state or states in which you will be employed. Such rules • Direct your energy toward achieving your goal within a advise you of the application process, any testing or fees specific time frame. involved, continuing education requirements, and the sta- • Goals must be more than wishes; they must be a visualization of what you expect to achieve. tus of any reciprocity with the ARRT. Visit the ARRT web- • Post your goals where you can see them daily, and share site at http://www.arrt.org to obtain a complete list of state them with the people who are significant in your life. agencies responsible for credentialing and requirements. • Shared goals are more likely to be met. Because state and national continuing education require- • Goal statements use the words “I will.” ments may differ, it is the responsibility of the individual • Setting goals should not be taken lightly, but it should not be a difficult task. technologist to keep abreast of the current requirements for continuing education. Neither state nor national agencies accept a lack of knowledge of the rules and regulations as an 204 PART 2 Career Planning

excuse for failure to meet the requirements. An insufficient registered. Be certain to keep copies of all documents for number of continuing education credits may result in the audit purposes. issuance of probationary status, the levy of fines by the state, Technologists who fail to meet the ARRT continuing or loss of the ability to work. education requirements are placed on probationary status You need to renew your certification with the ARRT by the ARRT. This means the technologist must make up each year, and you will need to submit proof of continuing continuing education credits by a specific date and keep up education activities every 2 years (known as a biennium). with credits in the current biennium. Failure to satisfy pro- This may be accomplished by documenting 24 hours of bationary requirements can lead to further sanctions up to continuing education for that biennium. These hours must and including a requirement for re-examination. Inquiries be continuing education activities that have met the crite- submitted to ARRT by employers receive a response that ria established by the ARRT and may include educational includes a notation of probationary status or revocation; activities you completed in order to qualify to take another this could result in your rejection as a job applicant or loss ARRT-approved exam in an area of radiologic technology in of employment. which you were not previously credentialed. Consult with Penalties regarding noncompliance with state continu- ARRT to verify such activities will be accepted. Beginning ing education requirements vary by state. Be sure to visit January 1, 2018, merely passing the additional exam does http://www.arrt.org often and read all of the information not count toward CE requirements. sent to you from the ARRT, particularly the “Stories of You must comply with the ARRT rules governing con- Quality Patient Care—Annual Conversation with Regis- tinuing education beginning with the first day of your birth tered Technologists.” month after you pass the radiography exam. Your subse- It is your responsibility to learn about modifications to quent bienniums then occur in your birth month. State the continuing education requirements. Be sure to read all of continuing education requirements may differ on their due the information sent to you from the ARRT. You should also dates. Be sure to keep the two sets of requirements clear. You remain alert for changes to such requirements in your state. should choose continuing education activities based on the Take time to review the ARRT’s “Continuing Educa- area of practice that would meet your needs and the needs tion Requirements” at http://www.arrt.org. This is your best of your patients. Remember, this is your practice of radiog- source for complete up-to-date information on continuing raphy. What activities would help you be a better caregiver education requirements along with frequently asked questions and imaging technologist? (FAQs). Your instructors can assist you with questions, or you States may differ on the type of activities that satisfy their may contact the ARRT office by telephone at 651-687-0048. continuing education requirements. Know the law in your state, and keep files on both state and ARRT requirements, Continuing Education Opportunities as applicable. As a registered technologist, it is your responsibil- There are many opportunities to obtain continuing educa- ity to know whether the continuing education program tion credits. The primary mission of your professional soci- you are attending has been approved and to obtain the eties is continuing education. Become an active member of necessary documentation proving your participation in the American Society of Radiologic Technologists (ASRT). the activity. As an attendee, you are not responsible for Through its sponsorship of conference events, numerous submitting a program for approval to obtain credit. The online programs, and its Directed Readings in the journal sponsor of the event seeks approval before the date of the Radiologic Technology, you can obtain a considerable portion presentation. The coordinator of a continuing education of your continuing education credits. The ASRT may be program can answer questions concerning the approval visited at http://www.asrt.org. of the event. The various state affiliate societies of the ASRT provide At the end of each biennium, you must provide proof many continuing education opportunities every year. Ask that you have satisfied the continuing education require- your instructors or radiologic technologists in clinical set- ment. Keep the original attendance documents for at least tings for membership information. As part of the state soci- 1 year beyond the 2-year period. The ARRT may conduct ety, your local professional society may have monthly or random audits to verify such documentation. The docu- quarterly meetings that stress continuing education. Take mentation must show the date of the program; title and advantage of these meetings. content; number of contact hours; and signature of an indi- If you choose a career in any of the radiologic specialties, vidual associated with the program, such as the speaker, education, or management, there are many other profes- instructor, or coordinator. The documentation should also sional organizations you may join. Each organization offers include a continuing education reference number pro- approved continuing education as part of its mission. Being vided by the Recognized Continuing Education Evaluation an active member of a professional society helps ensure that Mechanism (RCEEM). It is a good idea to set up your own you are informed about the continuing education programs file for continuing education for both the ARRT and the that will contribute most to your skill development. state requirements before you graduate so that it will be Continuing education is a vital part of your medical radi- in place and ready for immediate use as soon as you are ography practice. View it as an opportunity to learn and CHAPTER 7 Career Paths 205

enhance your skills rather than as an imposed obligation. • Consult “Continuing Education (CE) Requirements” at Attend programs that you know will help you become a bet- http://www.arrt.org. ter technologist. Take an active part in these events, both as • Continuing education opportunities include ASRT an attendee and as a coordinator. Conduct your own pre- (sponsored programs and Directed Readings), state sentation for a more complete learning experience. You will and local radiologic technology conferences, and employer-sponsored approved activities. find that such activities enhance your professional image • CQR provides the opportunity to document up-to-date and gain you the respect and admiration of your colleagues. skills and knowledge. Stay in regular contact via http://www.arrt.org and http:// www.asrt.org.

Radiologic Specialties Continuing Qualification Requirements (CQR) No one can predict to what height you can soar. Even you will not know until you spread your wings. Continuing Qualification Requirements (CQR) are required As demand increases for radiologic technologists with every 10 years for registered technologists in addition to the multispecialty capabilities, many radiography students, continuing education requirement. Documenting continued graduates, and practicing technologists are considering qualifications through the use of time-limited certificates furthering their education in imaging, therapy, educa- is the next logical step beyond testing and certification tion, or management. Other radiologic clinical special- (entry-level knowledge), registration (annual renewal and ties include: diagnostic medical sonography, nuclear compliance with ethical requirements), and continuing medicine technology, radiation therapy, CT, angiography, education (biennially). Beginning approximately 7 years MRI, quality management, interventional technology, into the 10-year period from the original date of certifica- mammography, and bone densitometry. Credentialing tion, technologists will have to demonstrate, choosing from in these fields is evolving rapidly, with additional edu- a choice of ARRT-approved activities, that they have kept cational requirements and clinical requirements being up with changes in their specific field and the core knowl- established. Numerous education programs are offered in edge required to practice. those areas, and an online search of such opportunities is Requirements may include compiling a professional pro- recommended. file, conducting a self-assessment and completing targeted Information concerning advanced level, or post pri- learning activities. These requirements are congruent with mary, exams in these areas is available from the ARRT. The the mission of the ARRT regarding high patient care stan- requirements for all specialty areas could change at any dards. Note that retaking the entry-level certification exam time; the appropriate credentialing agencies listed in this will NOT be a requirement. chapter should be contacted when the technologist is pur- Regulatory agencies are placing more emphasis on suing a specialty. accountability for individuals practicing in the health care Information about the specialties presented in this chap- professions. CQR is an integral part of your practice. Be ter provides you with access to the website of the profes- certain to remain current on the requirements by visiting sional organization associated with each specialty. The http://www.arrt.org often. websites give you access to the most current and accurate listings of all educational programs in the United States accredited by that organization and the certification require- KEY POINTS ments. Because certification requirements and educational Continuing Education programs are subject to change for various reasons, the interested professional should use the websites for such • Quality patient care dictates that you have the most information. current knowledge and skills needed to practice For each exam and specialty listed in this chapter, it radiologic technology. is important to contact the certifying organization(s) • Mandatory continuing education was established to ensure the continued competence of clinicians. for details regarding specific clinical requirements that • States may have their own continuing education may have to be documented as part of the application requirements. process. This chapter is meant to be informational only • ARRT requires proof of 24 hours of continuing education and does not attempt to take the place of the formal and activities every 2 years (known as a biennium). comprehensive handbooks published by the respective • The continuing education requirement may be accomplished by documenting 24 hours of continuing organizations. education activities that have met the criteria established by the ARRT. Diagnostic Medical Sonography • Keep continuing education documents for at least 1 year beyond the biennium for possible ARRT audit. Educational programs in sonography may be 1½, 2, or 4 years in length, depending on the curriculum offered and 206 PART 2 Career Planning

the inclusion of earned credit hours for an academic degree. For information on a career as a nuclear medicine tech- The course of study involves biology, sectional anatomy, nologist, contact the following organizations: patient care, physics and equipment of sonography, diag- American Society of Radiologic Technologists nostic procedures, imaging, and image evaluation. Clinical Albuquerque, NM education also constitutes a major portion of the program. http://www.asrt.org Use of the following websites will ensure that you obtain the Society of Nuclear Medicine and Molecular Imaging most accurate, current information available. Reston, VA For information on a career as a diagnostic medical http://www.snmmi.org sonographer, contact the following organization: For a listing of accredited educational programs in Society of Diagnostic Medical Sonography nuclear medicine technology, contact: Plano, TX Joint Review Committee on Education in Radiologic http://www.sdms.org Technology For a listing of accredited educational programs in sonog- Chicago, IL raphy, contact: http://www.jrcert.org The Committee on Accreditation of Allied Health Edu- For information on certification exams in nuclear medication Programs cine technology, contact either: http://www.caahep.org American Registry of Radiologic Technologists For information on certification exams in sonography, St. Paul, MN contact either: http://www.arrt.org American Registry of Diagnostic Medical Sonographers Nuclear medicine exam offered: Rockville, MD Nuclear medicine http://www.ardms.org or Exams offered for sonographers: Nuclear Medicine Technology Certification Board Abdomen Tucker, GA Adult echocardiography http://www.nmtcb.org Breast Nuclear medicine exams offered: Fetal echocardiography Nuclear medicine Musculoskeletal sonography Nuclear cardiology Obstetrics and gynecology Positron emission tomography (PET) Pediatric echocardiography Nuclear medicine advanced associate Pediatric sonography Sonography principles and instrumentation Radiation Therapy Technology Vascular technology or Educational programs in radiation therapy technology may American Registry of Radiologic Technologists be 1, 2, or 4 years in length depending on the curricu- St. Paul, MN lum offered and the inclusion of earned credit hours for http://www.arrt.org an academic degree. The course of study involves biology, Exams offered for sonographers: radiation oncology, pathology, radiation biology, physics Sonography (primary and post primary exam) and equipment of radiation therapy, intensity modulated Vascular sonography (post primary exam) radiation therapy, dosimetry, computer technology, and Breast sonography (post primary exam) quality assurance. Use of the following websites will ensure that you obtain the most accurate, current information Nuclear Medicine available. For information on a career as a radiation therapist, con- Educational programs in nuclear medicine technology tact the following organization: may be 1, 2, or 4 years in length, depending on the cur- American Society of Radiologic Technologists riculum offered and the inclusion of earned credit hours for Albuquerque, NM an academic degree. The course of study involves biology, www.asrt.org anatomy, patient care, nuclear physics and instrumentation, For a listing of accredited educational programs in radia- computer technology, biochemistry, radiopharmacology, tion therapy technology, contact: radiation biology and health physics, radiation protection, Joint Review Committee on Education in Radiologic immunology, radionuclide therapy, and statistics. Diagnos- Technology tic procedures, imaging, and image evaluation, including Chicago, IL extensive clinical education, also constitute a major portion www.jrcert.org of the program. Use of the following websites will ensure For information on the certification exam in radiation that you obtain the most accurate, current information therapy technology, contact: available. American Registry of Radiologic Technologists CHAPTER 7 Career Paths 207

St. Paul, MN environment.”* Radiologist assistants are ARRT-certi- http://www.arrt.org fied radiographers who have “successfully completed an Radiation therapy exam offered: advanced academic program encompassing a nationally Radiation therapy recognized radiologist assistant curriculum and a radiologist directed clinical preceptorship.”* Working under the Other Imaging Specialties supervision of a radiologist, “the Radiologist Assistant performs patient assessment, patient management and Education in other imaging specialties may be provided on selected exams.”* the job or in courses that are one semester or one academic Education of radiologist assistants is based at the bac- year in length depending on the curriculum offered, the calaureate and postbaccalaureate levels. The ASRT has current credentials of the radiologic technologist, and the written a core curriculum for a bachelor of science in inclusion of earned credit hours for an academic degree. radiologic sciences (B.S.R.S.) degree. The ASRT states The course of study should provide educational opportuni- that the radiologist assistant has the following areas of ties specific to the imaging modality, including pathology, responsibility: radiation biology, anatomy, patient care, physics and instru- 1. Participate in patient assessment, patient management, mentation, computer technology, radiation protection, and patient education diagnostic procedures, imaging, image evaluation, quality 2. Perform selected radiology procedures including, but not assurance, and clinical education. The imaging specialties limited to, fluoroscopy that might be included are: 3. Evaluate image quality and perform initial image obser- Angiography (all types) vations* Bone densitometry For information on a career as a radiologist assistant, CT contact either: MRI American Society of Radiologic Technologists Mammography Albuquerque, NM Quality management http://www.asrt.org Use of the following websites will ensure that you obtain American College of Radiology the most accurate, current information available. http://www.acr.org For information on a career in these specialty areas, For a listing of educational programs for radiologist assis- contact: tants, contact: American Society of Radiologic Technologists American Society of Radiologic Technologists Albuquerque, NM Albuquerque, NM http://www.asrt.org (search by topic) http://www.asrt.org Alternatively, use any comprehensive Internet search For information on the certification exam for radiologist engine, such as Google (search by topic). assistant, contact: For a listing of educational programs for these imaging American Registry of Radiologic Technologists specialties, use any comprehensive Internet search engine, St. Paul, MN such as Google (search by topic). http://www.arrt.org For information on certification exams in these specialties, contact: Radiography Educator American Registry of Radiologic Technologists St. Paul, MN One of the fastest growing specialties in radiologic tech- http://www.arrt.org nology over the next 10 to 15 years will be in the area Post primary exams offered other than sonography: of radiography education. There are currently nearly 800 CT radiography programs in the United States. They are MRI (also a primary exam) staffed, depending on size and enrollment, with direc- Cardiac interventional radiography tors, clinical coordinators, instructors, and laboratory Vascular interventional radiography assistants. Similar to a large percentage of the population Mammography as a whole, radiography educators are nearing retirement Quality management in unprecedented numbers. For registered technologists Bone densitometry who enjoy working with students and teaching, countless opportunities for career advancement and great satisfac- Radiologist Assistant tion will be available. The profession will need a steady supply of educators to keep its programs functioning and As structured by the ASRT, a radiologist assistant is “an to graduate the numbers of radiographers who will be advanced-level radiologic technologist who works under needed in the coming decades. The need for educators in the supervision of a radiologist to enhance patient care by assisting the radiologist in the diagnostic imaging * American Society of Radiologic Technologists, http://www.asrt.org 208 PART 2 Career Planning

all of the medical imaging and therapy professions will be Academic Degrees great. Radiography education is highlighted here because the need will be greatest in that field. You cannot discover new oceans unless you have the courage to If you are interested in a career specialty in radiography lose sight of the shore. education, prepare by earning degrees as follows, in addition An increasing number of radiography students and tech- to R.T.(R) credentials: nologists are interested in pursuing higher level academic • Program director: Master’s degree (consider radiologic degrees. This is particularly true for individuals seeking a technology, education, adult education, curriculum career in radiology management or education. Master’s design) degrees are required of radiography program directors. Bacca- • Clinical coordinator: Baccalaureate degree or master’s laureate degrees are required of clinical coordinators and full- degree (consider radiologic technology, education, adult time instructors. Others would like to pursue degrees because education, curriculum design) they enjoy learning or would find the achievement fulfilling. • Instructor or laboratory assistant: Baccalaureate degree Some hope to expand their earning potential or raise the level (for full-time instructors), with strong clinical experi- of their professional status. The baccalaureate degree is con- ence, a great interest in teaching, and proven expertise in sidered the professional level for radiologic technologists. radiography The U.S. Departments of Education and Labor possess For information on requirements for becoming a radiog- ample data to support the contention that earnings and employ- raphy program official or instructor, contact the following ment opportunities are greater for individuals who have higher organization: levels of education. Regardless of the motivation, career plan- Joint Review Committee on Education in Radiologic ning and goal setting must be based on accurate information. Technology Individuals interested in pursuing advanced degrees should Chicago, IL visit the institution’s website and request the latest edition of http://www.jrcert.org the college or university catalog to determine what curriculum For information specific to radiography educators, con- is offered. Information available on the Internet also provides tact the following organizations: listings of degree programs as they become available. Association of Collegiate Educators in Radiologic Tech- As with many other health professions, an advanced degree nology (ACERT) in radiologic technology is not required for career advance- http://www.acert.org ment. However, baccalaureate and master’s degrees in business, Association of Educators in Imaging and Radiologic management, and education have become increasingly impor- Sciences (AEIRS) tant. You should carefully define your career goals and pursue http://www.aeirs.org advanced education opportunities that are specific enough to provide skills in certain areas but broad enough to allow for Imaging Manager flexibility. Advancing to higher levels of responsibility in radiologic technology no longer depends entirely on moving up In many clinical environments, individuals advance into through the ranks; a solid college education is required. management, shift supervisor, or radiology administrative If an advanced degree is among your career goals, begin positions by promotion. In such situations, promotion planning now. Requests for information take time. The use occurs because an individual has proved to be exemplary of websites greatly expedites the process. The sooner you in some field of clinical work. If you are planning a career acquire the needed information, the sooner you will be able in radiology management, seriously consider college degrees to establish your plans for further education and achieve that provide you with the managerial and legal founda- your desired goals. tion to be effective in management. Managing the human Consider interviewing radiologic technologists at your and physical resources in an imaging or therapy depart- clinical sites who are currently enrolled in degree complement requires mastery of an entirely different set of skills. tion programs. They can provide helpful information about Consider a master’s degree in radiologic technology, man- the college or university in which they are enrolled. agement, communication, human resources, or business For specific college and university information, visit the administration. institution’s website or use major search engines, such as For information on degrees in these areas, use any com- Google, typing in keywords such as “radiologic technology,” prehensive Internet search engine, such as Google (search “radiography,” and “radiologic technology degree.” by degree). As you begin planning for an advanced degree, keep in For information on a career as an imaging manager mind you will already have at least an associate’s degree by the and for the exam for a certified radiology administrator, time you graduate from your radiography program. This places contact: you nearly halfway to a 4-year degree. Your program director AHRA: The Association for Medical Imaging Management. may have advice about writing a portfolio of education, clini- Sudbury, MA cal, and work experiences to help you receive additional college http://www.ahraonline.org credit for what you already know and have accomplished. CHAPTER 7 Career Paths 209

The work environment of the twenty-first century KEY POINTS requires that you have as much knowledge and as many credentials as possible to advance in your career. Now is a good Radiologic Specialties and Academic Degrees time to begin planning and setting goals for a lifetime of learning and achievement! • Demand is increasing for radiologic technologists who have multispecialty capabilities. • Specialties include: diagnostic medical sonography, nuclear medicine technology, radiation therapy technology, CT, angiography, MRI, quality management, interventional technology, mammography, and bone densitometry. • Formal classes in person or online should be attended whenever possible. • Information concerning advanced level, or post primary, exams is available from the ARRT. • Visit the website of the professional organization associated with each specialty for specific educational, clinical, and credentialing requirements. • Other specialties to be considered include radiography educator and imaging department administrator or manager. • Academic degrees enhance career opportunities in every aspect of radiologic technology. 8 Writing a Professional Resume

Purpose of a Resume this way can be time-consuming, but it is one method for reaching a large number of prospective employers. Your resume serves as your professional calling card. Its pur- In certain situations, the student or graduate radiog- pose is to obtain an interview. It is a summary of your aca- rapher may have an interview with a radiology manager demic and work history and relevant accomplishments and who has not yet seen his or her resume. For this reason, it credentials. It should be brief (i.e., one to two pages). It is is always a good idea to take a printed copy of the resume essentially a snapshot of your career to date. In addition to and give it to the radiology manager at the interview. offering samples of resumes, this chapter describes ways to Similar to appropriate attire and grooming, a professional use the resume and provides the rationale for including or resume can make a powerful first impression during an excluding certain information. interview. There are probably as many different styles and formats for resumes as there are instructors attempting to describe Contents of a Resume them. Take advantage of your radiography instructor’s expertise in this area. In addition, local colleges may have In addition to ensuring that you have the appropriate a learning resource center, a writing center, or a career writing tools available, you should spend time thinking counseling center from which you can obtain additional guidance. There are many books available on the subject of writing resumes. In addition, numerous software packages provide guidance on writing resumes. With all of these resources to choose from, writing a resume can become a Date dizzying experience. The material presented in this chapter was developed for my courses and has been used by stu- Director of Radiology dents and graduates. XYZ Hospital The resume may be used in three ways. Most com- Main Street monly, it will be (1) electronically attached to the online Anytown, USA 01234 job application form submitted to the human resources department. It may also be (2) sent as part of a mailing or Dear Director: an emailing to prospective employers and followed with Enclosed please find my professional resume a telephone call or (3) left with an interviewer after an outlining my education and work experiences. I am appointment. very interested in being considered for Often the student or graduate radiographer wishes to employment in your department of radiology in the position of staff radiographer. I appreciate indicate availability to numerous prospective employers in whatever time and attention you are able to give to a certain geographic area. The resume, accompanied by a this inquiry. cover letter, may be mailed or emailed to the directors of I will call you in a few days to see what radiology at all facilities in the area where the student is employment opportunities you may have available. interested in working. Although this is the least effective method to use in a job search, a well-constructed resume Sincerely, with an appropriate cover letter can produce results. Figure 8-1 shows a sample cover letter to accompany the Enclosure resume in these situations. Such a mailing should always be followed by a personal telephone call to the radiology manager, as promised in the cover letter. Following up in • Figure 8-1 Sample cover letter, general mailing.

210 CHAPTER 8 Writing a Professional Resume 211

about what to include in the resume and what to exclude. in another specialty, such as “To obtain a position as an Include all postsecondary (i.e., after high school) education. entry-level radiographer; desire to cross-train in computed You should account for all of your time since high school. tomography.” Careful consideration should be given to the Include all professional society memberships, ARRT cre- goal statement. If the wording suggests that you absolutely dential or state licensure numbers, awards, and accomplish- must have the opportunity to cross-train in other modali- ments on the resume. ties, you would be eliminated from consideration if the The resume should contain only information that is rel- prospective employer is looking for a staff radiographer evant to your accomplishments and goals as a professional. only. Wording such as “To obtain a position as an entry- Information of a personal nature (beyond that presented in level radiographer; willing to be cross-trained in other the next section) or data that could be used to discrimi- modalities” indicates your desire to expand your horizons nate should be excluded from the resume. Your resume is but without the sense of urgency conveyed by the previous an opportunity to advertise yourself in your absence. Con- statement. struct it wisely. The goal statement may also be altered depending on where you are seeking employment. If you know the pro- Writing the Resume spective employer is seeking radiographers who definitely want to cross-train, that interest should be included in Figures 8-2, 8-3, and 8-4 show three resumes. Figure 8-2 your goal statement. In addition, if one of your goals could have been written by a student in the final year or is to cross-train and you are unwilling to accept a posi- semester of the radiography program. Figure 8-3 is a sample tion that does not offer that opportunity, you should of a resume of a recent graduate. Figure 8-4 is similar, but include it in your goal statement, realizing that you goes into greater detail concerning the clinical experiences may be excluded from consideration if such a position gained while being a student. With the increasing com- is unavailable. Words in the goal statement that identify petitive nature of the radiography job market, this style of the strength of your interest are “desire to cross-train” or resume can be used to highlight specific clinical experiences “willing to cross-train.” that may set you apart from other applicants. Seriously con- As you prepare to write your resume and begin setting sider its use. These resumes present applicants with slightly your professional goals, give them serious consideration. different backgrounds and so include different information. The goal statement may include you in the final group of Your resume is likely to be a variant of these. Remember, candidates for a position, or it may exclude you immedi- brevity is the rule when constructing your resume. How- ately, depending on how it is worded. As a final example, ever, do not use abbreviations. Keep your resume polished consider the goal statement of an applicant to a clinic or and proper. urgent care setting. The responsibilities in these positions often are multifaceted. A goal statement such as “To obtain Personal Data a position as a radiographer; willing to perform venipuncture, simple laboratory procedures, and electrocardiograms, The first section should include your name, followed by the and take patient histories and vital signs” indicates not only address and telephone number (and email address; this is a willingness to learn new procedures but also an ability to optional) at which you may be reached during your current be flexible and work as a team member in a small clinic job search. If your address and telephone number change setting. Conversely, if you have no desire to perform these during the course of your job search, a prospective employer other functions, you should not include such places in your would be unable to contact you, possibly eliminating you job search. as a candidate for the position. If you must change your address and telephone number after submitting the resume, Employment Experiences inform prospective employers in writing. No additional personal information should be included Beginning with your most recent employment and work- on the resume. Specific items to be excluded are date of ing backward, you should list all employment experiences birth, gender, race, marital status, religious affiliation, num- related either to health care or to working with the pub- ber of children, disabilities, hobbies, and any other data that lic. Indicate the month and year that each position began are irrelevant to your status as a job seeker. Although a pro- and ended, the name of the employer, the location of the spective employer may not use such information, including employer, and a simple phrase describing your responsibili- it on your resume brings it to the forefront. ties. It is unnecessary to list the names of supervisors or the salary you received. It is also unnecessary to account for Goal Statement every job held since high school. The resume is your statement of professional experience. Include the positions that As shown in the examples, the next section of the resume demonstrate your ability to work with people and willing- should include your goal statement. The goal statement ness to take on responsibility. Try to avoid lapses in dates can be as simple as “To obtain a position as an entry-level whenever possible. Your work experience and education radiographer,” or it may include your desire to cross-train should blend into a seamless timeline. 212 PART 2 Career Planning

Personal Data

Name Address City, State, Zip Code Telephone Number Email Address

Goal

To obtain a position as an entry-level radiographer; willing to cross-train in computed tomography.

Employment Experience

September 20__-Present

Front Office Clerk Medical Imaging Department City Medical Center This Town, State Duties: Greet patients arriving for radiographic exams; update electronic medical record

November 20__-August 20__ Certified Nursing Assistant Extended Care Unit County Rehabilitation Center Our Town, State Duties: Provided care to patients such as bathing, grooming, basic exercise, and assistance with meals

Education

June 20__-Present Radiography Program Name Our Community College (or) Our Hospital This City, State Graduation scheduled for May 20__

Fall 20__-Spring 20__ Radiography program prerequisites Our Community College This Town, State Earned 48 semester hours in liberal arts and sciences

Professional Accomplishments, Associations, and Credentials

• Taking American Registry of Radiologic Technologists radiography exam, May 20__ • Student member, American Society of Radiologic Technologists • Student member, This State Society of Radiologic Technologists • Awarded First Place for scientific exhibit entitled “Osteogenesis Imperfecta” at State Society Radiologic Technologists Annual Conference • Participant, Scholar Bowl, State Society of Radiologic Technologists Annual Conference • Certified Nursing Assistant, credentialed by Our State

References available upon request.

• Figure 8-2 Sample resume, second-year student. CHAPTER 8 Writing a Professional Resume 213

Personal Data Name Address City, State, Zip Code Telephone Number Email Address

Goal To obtain a position as an entry-level radiographer; desire to cross-train in mammography.

Employment Experience December 20__-Present Patient Transporter Department of Imaging XYZ Area Hospital This Town, State Duties: Transport inpatients to and from imaging department

May 20__-November 20__ Great Food Restaurant This Town, State Duties: Greeted customers at their table; took order, served food

Education August 20__-July 20__ Radiography Program Name Our Medical Center (or) Our College That City, State Graduated July 20__ Awarded Diploma in Medical Radiography (or) Associate in Applied Sciences Degree

Spring 20__-Spring 20__ Liberal Arts Coursework Community College This Town, State Earned 36 semester hours

Professional Accomplishments, Associations, and Credentials • Took Registry exam in August; passed; awaiting credentials (or) Registered by the American Registry of Radiologic Technologists, #123456 through January 20__ • Credentialed by the State of __, #987654, through July 20__ • Active member, American Society of Radiologic Technologists • Active member, This State Society of Radiologic Technologists • Member of student team winning first place in radiography scholar bowl at This State Society of Radiologic Technologists Annual Conference, 20__ • Awarded first place for scientific paper presentation entitled “Cervical Spine Injuries” at This State Society of Radiologic Technologists Annual Conference, 20__

References available upon request.

• Figure 8-3 Sample resume, recent graduate. 214 PART 2 Career Planning

Personal Data

Name Address City, State, Zip Code Telephone Number Email Address

Goal (optional) To obtain a position as an entry-level radiographer; desire to cross-train in…

Employment Experience

December 20__-Present Patient Transporter Department of Imaging XYZ Area Hospital City, State Duties: Transport inpatients to and from imaging department

May 20__-November 20__ Great Food Restaurant City, State Duties: Greeted customers at their table; took order, served food; followed up for positive guest experience

Radiography Education

August 20__-July 20__ Radiography Program Name Our College (or) Our University (or) Our Hospital City, State Graduated July 20__ Awarded Associate (or) Baccalaureate degree

Radiography Clinical Education Experiences

Rotated to three clinical sites during my radiography program:

Small rural hospital - became proficient at routine radiographic and fluoroscopic procedures; followed patients from admission to the imaging department until completion of their exam and discharge from the department; operated (brand name of equipment) and (brand name of PACS); observed CT and sonography when possible

Large medical center - in addition to radiographic and fluoroscopic procedures, passed all competencies in portables and surgery; became proficient in the use of (brand name of equipment) and (brand name of PACS); became comfortable with evaluating acquired images, identifying required anatomy, and determining the acceptability of the images; did multiple rotations through trauma imaging in the ED to increase competency level there; took advantage of rotations to CT, MRI, angiography, nuclear medicine, sonography, and radiation therapy; did additional rotation thorough sonography

Prompt care clinic - expanded skills to include (brand name of equipment) and (brand name of PACS); understanding of the operation of the clinic; developed enhanced history taking skills; participated in team effort among nursing, radiography, lab, and admissions to deliver exceptional patient care experiences

Radiography Program Prerequisites

Spring 20__-Spring 20__ College (or) University City, State Earned 36 semester hours

Professional Accomplishments, Associations, and Credentials

• Credentialed by the American Registry of Radiologic Technologists, through January 20__ • Credentialed by the State of __, through July 20__ • Active member, American Society of Radiologic Technologists • Active member, This State Society of Radiologic Technologists • Member of student team winning first place in radiography scholar bowl at This State Society of Radiologic Technologists Annual Conference, 20__ • Awarded second place for scientific paper and presentation entitled “Cervical Spine Injuries” at This State Society of Radiologic Technologists Annual Conference, 20__

References available upon request.

• Figure 8-4 Sample resume with clinical experiences CHAPTER 8 Writing a Professional Resume 215

Education Date Your resume should include all of the formal education you have acquired since high school, listed in reverse chronologic order (i.e., beginning with the most recent). It is unnecessary Director of Radiology XYZ Hospital to provide a detailed list of the courses studied. Rather, you Main Street may wish to indicate a broad area of study (e.g., liberal arts Anytown, USA 01234 and sciences, radiography program prerequisites, etc.). Some entries in this section are self-explanatory. A radiology man- Dear Director: ager would not require explanation of an entry such as “Radi- ography Program.” In each of your educational experience It was with great interest that I read your hospital’s advertisement for the position of staff radiographer. entries, indicate whether you graduated or received some form Enclosed please find my professional resume of certificate, diploma, or degree. The dates in this section, outlining the experiences and education that I along with the dates accompanying your employment history, believe qualify me for this position. should account for most of your time since high school. I wish to notify you of my interest in being employed in your department. I am also completing an application for employment in your Professional Accomplishments, Associations, Department of Human Resources and am and Credentials including a copy of my resume with it. I look forward to hearing from you regarding a personal In this section, you should list all professional organizations interview so that we may discuss our mutual needs and interests. to which you belong. Include any offices or other positions of responsibility you have held, such as being a mem- Sincerely, ber or chair of a committee. Examples of information for this section include membership in local, state, or national Enclosure professional societies; membership in student radiographer associations; and any professional licenses already held. • Figure 8-5 Sample cover letter, response to job posting. Awards for academic excellence, such as honors listings, and participation in competitions, such as research paper writing, scientific exhibits, and scholar bowls, should be concise cover letter, which can comprise the body of the included. You may also wish to include a list of your atten- email. Figure 8-5 shows a sample of a cover letter you can dance at state or national professional society meetings. adapt for your use. If you have not yet taken the ARRT exam, you should describe your status, such as “Taking ARRT exam in [list month].” If you have taken the exam but have not yet Appearance of the Resume and Cover received your credentials, describe your status such as “Took Letter Registry exam on August 20; passed; waiting for credentials.” Note there is no such status as “Registry eligible”; do As you compose your resume, you should create a rough not use the term. Radiology managers encounter this situa- draft and then refine the resume after proofreading it. It is tion routinely and are not dissuaded from considering your recommended that you have someone else read it as well. Be application because of your transitional status. If you have sure to use the “spell check” feature in your software. There received your credentials, you should indicate your ARRT should be no mistakes in your resume. number and expiration date. Do not include your test score. In most situations, you will attach your resume to an online application form. Be sure to convert your electronic References resume to PDF format before attaching it. If printing your resume, be sure to use a high-quality References are not listed on the professional resume. A laser or ink-jet printer. After printing, make certain there prospective employer provides space on the job applica- is no smeared ink or partially printed lines caused by a tion form for listing both work and personal references. For faulty printer. There are nearly as many different types of the resume itself, the statement “References available upon paper available as there are resume formats. The resume request” suffices. Be sure you have obtained the permission and cover letter should be printed on 60- to 75-lb text of the individuals you wish to use as references so that they paper that is preferably white or ivory, which provides a will be expecting inquiries from prospective employers. positive image for your resume. Because this paper has a heavier weight, it should not be folded. Avoid using Cover Letter copier-type paper; it is an inexpensive grade of paper and does not make a positive impression on the reader. In addi- If emailed in response to an actual job posting or adver- tion, many papers of this type produce a poorer printed tisement, the resume should always be accompanied by a image when used with a laser printer. If you are unfamiliar 216 PART 2 Career Planning

with paper types and weights, your writing center or retail • List all jobs held since high school, oldest first; include copy shop can provide you with information. If handling a all jobs that dealt with the public; emphasize jobs in paper copy, you should use a large manila envelope so the health care. resume lies flat and unfolded. • List all postsecondary education; high school should be left off. • Indicate whether you graduated and whether you Job Application received a certificate, diploma, or degree. • List offices or other positions of responsibility you have Students are often dismayed that after investing much time held, such as membership in local, state, or national and effort in writing a resume, they must still complete a job professional societies and membership in student application form. This is a standard practice for employers radiographer associations; any professional licenses already held; awards for academic excellence such as and is required by institutional accrediting agencies. honors listings; participation in competitions such as Assuming you are applying to an institution that uses research paper writing, scientific exhibits, and scholar online applications, have all of your information nearby bowls; and attendance at state or national professional when filling in the form. Again, be sure to attach a PDF society meetings. copy of your resume as directed by the online application • References are not listed on the professional resume. • Use spell check, proofread your resume, and have instructions. If you are using job search websites, most will someone else proof it as well. permit you to post your resume for employers to examine. • When applying online, attach the resume electronically. In either case, a professional resume, clearly indicating your • If printing, use high-quality 60- to 75-lb paper, white or professional experience and goals, will go a long way toward ivory, using a good printer. securing the position you desire. • Your resume is a statement of your professionalism that speaks for you in your absence. You may request former or current employers not be contacted. In addition, a detailed employment and reference check cannot be conducted without your signed authorization. Carefully read the statement on the application form before you sign it with the appropriate electronic signature. Proper preparation of a professional resume is not a task to be taken lightly. Spend the time needed to construct your resume carefully, and be aware of its impact on potential employers. Your resume is a statement of your professionalism that speaks for you in your absence.

KEY POINTS Writing a Professional Resume

• Your resume is a summary of your academic and work history and relevant accomplishments and credentials. • Keep resume length to one or two pages, as a snapshot of your career to date. • Include your name, address, phone number, and email address. • Exclude date of birth, gender, race, marital status, church affiliation, number of children, disabilities, hobbies, and any other data that are irrelevant to your status as a job seeker. • Include only information that is relevant to your accomplishments and goals as a professional. • Br evity is the rule. • Do not use abbreviations of any kind. • Resumes may be used as part of a mailing or emailing to prospective employers, left with an interviewer after an appointment, included with the job application form, or attached as a PDF document. • Pr epare a cover letter to accompany your resume if doing a mailing, or use the cover letter as the body of the email. • Include a simple goal statement. 9 Interviewing Techniques

Purpose of an Interview athletic shoes, are also inappropriate. Be careful not to over apply cologne or arrive at the interview smelling of If your resume is your detailed calling card, your personal smoke. Pay attention to details. It does little good to wear interview is your house call. It is your only opportunity to a clean, pressed business suit only to have the interviewer make a strong, lasting first impression with your possible see dirty fingernails. Similarly, proper grooming loses its future employer. Because of the legalities surrounding the impact when your cologne precedes you to the interview issue of discrimination, the personal interview may not be by 5 minutes. as detailed as it has been in the past. However, this does Conservative clothing is a must. Men should always wear not diminish its significance or the importance of proper a business suit or blazer, tie (optional), and dress slacks. preparation. Women should wear a business suit. Clothing must be The employer can use the personal interview to verify clean and free of wrinkles. Shoes (polished), socks, and belt information submitted on the resume or job application. It should complement the clothing. Hose must be free of runs. can serve as an opportunity for the employer to show you Hair should be neatly styled and pulled back if shoulder the facilities in which you may be working, familiarize you length or longer. Jewelry should be conservative and kept to with the equipment, and determine your experience with a minimum, including visible piercings. such equipment. The interviewer may also be interested in As your attire varies from these suggestions, the likeli- your career goals and plans for establishing a career. hood of a favorable impression on the interviewer decreases. Another purpose of an interview is for you to become Applying for a professional position requires that you dress acquainted with your prospective employer. It is also a and present yourself professionally. time for you to decide whether you want to work for that By taking the time to prepare your personal appearance department or organization if offered a job. As you pre- and dress professionally, you are telling the interview- pare for the interview, always remember it is a two-way ers that you respect their time and appreciate their seri- street. ous consideration of you as a job candidate. You are also making a statement about how you believe a professional Personal Appearance should appear, not only to potential employers but also to peers. The interviewers will assume that, although you There is no substitute for making a strong first impression would be wearing a professional uniform or even scrubs with the person or persons who will be conducting your at work, you would appear as neat and clean when car- interview. Like it or not, we are visual creatures, and your ing for patients as your appearance during the interview physical appearance during your initial contact with the suggests. receptionist and interviewers has a profound effect on their Because you will undoubtedly be nervous, your mouth perception of you as a potential employee. will likely be dry. Until the interview begins, use a breath How you choose to present yourself for your interview mint to keep your mouth moist and your breath fresh. Gum says a lot about your professional self-image. Regardless of chewing is never acceptable in a professional setting. Be cer- where you work, you represent that department or organi- tain your cell phone is turned off (not just on vibrate). zation to the patient or customer. Appropriate professional Another aspect of your appearance may also be reflected attire begins with the interview and continues every day in your postings on various social media. While useful as a once the job begins. communication link with friends and relatives, social media Dressing for social occasions varies by age group and are increasingly used by employers to evaluate a candidate geographic region. However, dressing for a professional for hire. Carefully consider what types of photos you post, job interview is fairly standard regardless of age or loca- what language you use, and what activities you promote in tion. What you choose not to wear is as important as your social media postings. what you do wear. For the interview, do not wear your If you were hiring someone for a position such as this, professional uniform. Casual attire and trendy clothing, what decision would you make based on what you see and such as blue jeans, casual slacks, shorts, T-shirts, and read in your social media postings? What impression would

217 218 PART 2 Career Planning

you have of your professionalism, habits, or activities? Your When you arrive at the interview site, you may want to interviewer wants to hire the best candidate for the position visit the restroom. Anxiety about the interview may make who will reflect the values, image, and reputation of their this necessary, but it also gives you the opportunity to make institution. Invest some time evaluating what you post or sure your hair and attire are presentable. When arriving at have someone look at it for you. You want to make the best the appropriate office, greet everyone as if they were going overall impression you can in a challenging job market. to conduct the interview. Many radiology managers ask receptionists their impressions of the interviewee. Preparing for the Interview Feeling nervous and apprehensive about an interview is normal, especially if you greatly desire the position. Try to To prepare for the interview, you should attempt to find convert your nervous energy into enthusiasm when speak- out as much about your potential employer as possible. If ing with others throughout the course of the interview. you cannot ascertain this information ahead of time, be prepared with questions about the employer you can ask during Interview Process the interview. When the interviewer approaches, stand and shake hands firmly. Make eye contact. A smile and an enthusiastic KEY POINTS (although not excessively demonstrative) attitude create Questions You May Wish to Ask the Interviewer a positive first impression. As the interview begins, try to appear as calm, comfortable, and professional as possible. • Why is the current position available? Maintain appropriate eye contact and smile. Maintain good • What is the annual rate of turnover in the imaging posture and remain alert. Be pleasant, avoid joking, and be department? attentive. Speak distinctly, and use appropriate terminology. • What is the overall harmony among employees in the department? Be a good listener. You may wish to bring up your career • How is the feedback from employee or patient goals as summarized in the goal statement on your resume. satisfaction surveys? Carefully indicate how you may be an asset to the depart- • What advancement opportunities are available, ment without sounding as though you are bossy, arrogant, including cross-training in other imaging modalities? or demanding. Answer the interviewer’s questions clearly, • Does the organization provide continuing education, in-service programs, or tuition reimbursement? avoiding very short or very long answers. Be prepared to • What is the financial security of the organization? discuss any items you have included on your resume. There have been numerous legal challenges in recent years to what are alleged to be discriminatory interview questions and techniques. Although the emphasis of such legal rul- Before the interview, you may wish to examine the organiza- ings has been to require the interviewer to ask only question’s most recent annual report (which is normally found tions that reveal your job qualifications, it is wise for you on the organization’s website). The overall reputation in the to know what can and cannot be asked in a job interview. community and the financial stability of your prospective This knowledge assists you in preparing for the interview. It employer are factors you should consider before accepting also makes you aware of your rights so you may recognize a job offer. potentially discriminatory situations. It should not be necessary to bring anything to the inter- Many interviewers begin an interview with the question view unless you have not previously submitted your resume “Tell us about yourself.” This type of wide-open question to the interviewer; if you have not, bring a clean copy inside can be an opportunity for you to expand on what you put a manila folder or large envelope. All the facts pertaining to on your resume, or it can also lead you to discussing per- your professional preparation are on the resume. If docu- sonal information that should not be discussed in an inter- mentation is required for any item, it may be submitted at a view. Although the question is seemingly harmless, you may later time to the department of human resources. Similarly, find yourself answering it by discussing your children, child your list of references is probably already entered on the job care issues, your family plans, your hobbies, etc. These items application form. If not, these may also be furnished later cannot be asked by the interviewer but can be ascertained to the human resources department. In most cases, individ- by having you talk about yourself. Remember to keep your ual department directors do not perform reference checks answer to this question focused on the position for which because of the legalities involved. you are interviewing and why you would make the best can- If you are unsure where the interview will be held, you didate to be hired. Do not delve into anything not related should find the building and the office several days ahead to the job. of time. You do not want to spend time searching for the Be prepared for behavioral interviews. Such interviews site on the day the interview is scheduled. You should allow probe your responses to various interpersonal and profes- plenty of time to get to your destination. If you arrive early, sional situations. Do not attempt to outwit the interviewer. there is always a waiting area. Arriving late for an interview It is best to answer the questions honestly and profession- is inexcusable. ally. Likewise, be prepared to be interviewed by radiology CHAPTER 9 Interviewing Techniques 219 supervisors or staff radiographers. This has become more is intentional, you may not wish to continue pursuing the commonplace in recent years. Bear in mind they must keep position. If blatant harassment or violation of ethical inter- their questions focused on the specific position for which viewing guidelines occurs, you must ask yourself whether you are interviewing. Because they are your peers does not you wish to work in such an environment, regardless of mean they may ask inappropriate or personal questions. how much you might desire the position. If either of these The following box lists topics that may be addressed situations develops, you may decide to conclude the inter- during an interview. They are relevant to the job and are view with a statement such as, “Thank you for your time, legitimate areas of inquiry. You may wish to write out your but I feel you are asking irrelevant questions in violation of answers ahead of time in anticipation of the interview. my rights. Please remove my name from consideration for Other interview questions not included in this list may also this position,” or you may opt to finish the interview and be appropriate and within current legal guidelines. remove your name from consideration in a follow-up email. Be careful not to answer questions on the topics in the KEY POINTS accompanying box. You are not required to answer them and should not volunteer such information. If you believe Questions You May Be Asked That Are Appropriate you have been discriminated against based on questionable and That You Should Be Prepared to Answer interview practices, you may wish to seek private legal coun- sel or remedy through the Equal Employment Opportunity • Any information you entered on the application form Commission (EEOC) as a last resort. Recommendations • Why you left your last job concerning legal issues that may arise during the interview • How your former employers view you • What your duties were in your last job or a summary of are beyond the scope of this text. A personal attorney is best your clinical rotations if you are a new graduate equipped to answer such questions. • What you liked or disliked about your previous jobs or your favorite or least favorite experiences as a student • What job duties interest you • The days or hours you are (or are not) available to work KEY POINTS • The size of the facility in which you previously worked • What you thought of your previous supervisors or Questions You May Be Asked That Are Not instructors (e.g., whether you got along, what kind of people they were, whether they were strict or Appropriate and That You Should Not Answer easygoing) • The kind of supervisor you prefer • Your age • How employee or student problems and complaints • Your birth date were resolved at your previous job or clinical site and • How long you have resided at your present address whether you thought it was a good procedure • Your previous address • How you would prefer to have employee problems and • The house of worship you choose to attend (if any) or complaints handled if hired for this job the name of your clergyperson • What wages you received at your previous job • Your family’s surname • Whether you were promoted and on what criteria the • Your birth name, if married promotion was based (e.g., merit, length of service) • Whether you are married, divorced, separated, • How much you expect an employer to communicate widowed, or single with you and to keep you involved in workplace activities • Who lives with you • Which mode of communication you prefer • How many children you have or intend to have • The ages of your children • Who will care for your children while you are working • How you will get to work (unless owning a car is a job The interviewer will probably provide you with information requirement) • Where a spouse or parent works or lives about the salary structure, benefits package, sick leave, and • Whether you own or rent your place of residence vacation time allowed. Although this information is impor- • The name of your bank or any information concerning tant to you, try to wait until the interviewer brings it up. In outstanding loan amounts this way, you will not appear to be interested only in money • Whether you have ever had your wages garnished or and benefits. filed bankruptcy • Whether you have ever been arrested In any interviewing situation, you should be aware of • If you have ever been convicted of a felony (this the types of questions that may not be asked. Although it question is illegal in many cities and states until a firm is not likely to occur in a truly professional organization, it job offer is presented to you) is always possible that you may be asked an inappropriate • Whether you have ever served in the armed forces of question. If you are asked an inappropriate question relat- another country • How you spend your spare time or to which clubs or ing to the subjects listed in the following box, you may wish organizations you belong to ask the interviewer, “Can you explain to me how this • Your position on labor unions or whether you have ever question relates to the requirements of this position?” Most been a member of a union likely, the interviewer will retract the question. However, • The nationality of your name if a series of improper questions is asked, and you realize it 220 PART 2 Career Planning

sure it is on good-quality paper and reinforces the positive Radiology Manager’s Name impression you have sought to make. Keep in mind this Imaging Center or Hospital Name Armstrong Avenue is basically a thank you letter and is not meant to provide My Town, OH 45895-1969 additional information about yourself. Most important, be sure to send it. Many individuals fail to follow up with a Dear Radiology Manager’s Name: letter, and consequently, you will stand out from the rest! Thank you for the opportunity to interview for the Interview Outcomes and Follow-Up position of staff radiographer. I appreciate the time you spent with me yesterday. It was a pleasure meeting you and seeing your imaging department. Even after a good interview, you may not be hired or take the job offer. The following box lists some of the possible I look forward to hearing from you regarding this position. reasons.

Sincerely, KEY POINTS

Why You May Not Be Hired Applicant, R.T.(R) • Your references were unsatisfactory. • Your interview created a poor impression; you did not • Figure 9-1 Sample interview follow-up letter. seem interested; you used poor grammar or other unacceptable communication skills. • You have had inappropriate social media postings. Do not allow the interviewer to take advantage of your • You are unable to work the required hours. friendly nature to ask questions that should not be asked or • You choose to reject the job offer because you are not to pry into personal aspects of your life. This is not a con- interested in the position. • You are not qualified for the position, or other versation between friends; it is a professional job interview. candidates were better qualified. If you conduct yourself professionally, a competent inter- • You did not pass the preemployment drug screening or viewer will respect you and your position. background check. The last impression can be as important as the first. You • Inconsistent or inaccurate statements were made on may wish to ask, “Is there anything else you’d like to ask your application form. • You are physically unable to perform the job duties; me?” At the conclusion of the interview, shake hands firmly, however, the Americans with Disabilities Act guidelines make eye contact, and thank the interviewer for the time must be considered. spent with you. The interviewer will probably give some • There was not a good match between what you had to indication of when the hiring decision will be made based offer and this employer’s needs. on the number of applicants and the date by which the position must be filled. As you leave, say good-bye to the administrative assistants you pass and thank them for their Following the guidelines and suggestions in this chapter assistance. will not guarantee employment. However, it will guarantee Immediately send or email a follow-up letter to the that you will present yourself as the true professional you interviewer. A sample is shown in Figure 9-1. If printed, be have worked so hard to become. 10 Employment Expectations

Entering the Health Care Workforce 7. Respond as appropriate to imaging study inquiries from patients. As you enter the workforce in medical radiography, the 8. Sequence imaging procedures to avoid residual con- individuals in charge of the facility in which you will trast material affecting future exams. work will have expectations of you as a professional. 9. Assume responsibility for medical equipment attached From their standpoint, it is reasonable to expect you will to patients (e.g., IVs, oxygen) during the imaging probe able to fulfill the requirements of your job descrip- cedures. tion. You are being hired because you have the abilities to 10. Follow environmental protection standards for han- function as an entry-level radiographer. Ultimately, the dling and disposing of biohazardous materials (e.g., most important expectations you must exceed are those sharps, blood and body fluids). of the patient. 11. Provide for patient safety, comfort, and modesty. The task inventory conducted by the American Regis- 12. Notify appropriate personnel of adverse events or try of Radiologic Technologists (ARRT) reflects the skills incidents (e.g., patient fall, wrong patient imaged). performed by entry-level radiographers responding to the 13. Communicate scheduling delays to waiting ARRT survey. Not only does this form the basis of the patients. radiography exam content specifications listed in Chapter 14. Demonstrate and promote professional and ethical One, it also coincides with the terminal competencies of behavior. your educational program. You should also be aware your 15. Verify informed consent as necessary. new employer will have expectations you are competent 16. Recognize abnormal lab values relative to the imaging in these skills regardless of where you attended school. study ordered. The task inventory is provided here so you can under- 17. Communicate relevant information to others (e.g., stand the technical skills expected of you as you enter the MDs, RNs, other radiology personnel). workforce. 18. Explain procedure instructions to patient or patient’s family. Task Inventory* 19. Practice Standard Precautions. 20. Follow appropriate procedures when caring for Completion of your educational program should enable you patients with communicable diseases. to carry out the following tasks: 21. Use immobilization devices, as needed, to prevent 1. Confirm patient’s identity. patient movement and/or ensure patient safety. 2. Evaluate patient’s ability to understand and comply 22. Use proper body mechanics when assisting a with requirements for the requested examination. patient. 3. Obtain pertinent medical history. 23. Use patient transfer devices when needed. 4. Manage complex interpersonal interactions within 24. Prior to administration of a medication other than a the workplace in an effective manner. contrast agent, review information to prepare appro- 5. Explain and confirm patient’s preparation (e.g., diet priate type and dosage. restrictions, preparatory medications) prior to begin- 25. Prior to administration of a contrast agent, review ning imaging examinations. information to prepare appropriate type and dosage. 6. Review imaging exam request to verify accuracy and 26. Prior to administration of a contrast agent, determine completeness of information (e.g., patient history, if patient is at risk for an adverse reaction. clinical diagnosis, physician’s orders). 27. Use sterile or aseptic technique when indicated. 28. Perform venipuncture. * From American Registry of Radiologic Technologists: Radiography exam 29. Administer IV contrast agents. task inventory, St Paul, MN, 2015, ARRT. Implementation date January 30. Observe patient after administration of a contrast 2017. agent to detect adverse reactions.

221 222 PART 2 Career Planning

31. Follow environmental protection standards for han- 58. Operate electronic imaging and record keeping dling hazardous materials (e.g., chemotherapy IV, devices including: radioactive implant). a. Computed radiography (CR) with photostimu- 32. Obtain vital signs. lable storage phosphor (PSP) plates 33. Recognize and communicate the need for prompt b. Direct radiography (DR) medical attention. c. Picture archival and communication system (PACS) 34. Administer emergency care. d. Hospital information system (HIS) 35. Explain post-procedural instructions to patient or e. Radiology information system (RIS) patient’s family. f. Electronic medical record (EMR) 36. Maintain confidentiality of patient information. 59. Modify technical factors to correct for noise in a digi- 37. Clean, disinfect, or sterilize facilities and equipment, tal image. and dispose of contaminated items in preparation for 60. Remove all radiopaque materials from patient or table next examination. that could interfere with the image (e.g., clothing 38. Document required information on patient’s medi- removal, jewelry removal). cal record (e.g., imaging procedure documentation, 61. Perform post-processing on digital images in prepara- images). tion for interpretation. a. On paper 62. Use radiopaque anatomical side markers at the time of b. Electronically image acquisition. 39. Evaluate the need for and use of protective shielding. 63. Add electronic annotations on digital images to indi- 40. Take appropriate precautions to minimize radiation cate position or other relevant information (e.g., time, exposure to the patient. upright, decubitus, post-void). 41. Question female patient of childbearing age about 64. Select equipment and accessories (e.g., grid, compen- date of last menstrual period or possible pregnancy sating filter, shielding) for the examination requested. and take appropriate action (e.g., document response, 65. Explain breathing instructions prior to making the contact physician). exposure. 42. Restrict beam to the anatomical area of interest. 66. Position patient to demonstrate the desired anatomy 43. Set technical factors to produce diagnostic images and using anatomical landmarks. adhere to ALARA. 67. Modify exposure factors for circumstances such as 44. Document radiographic procedure dose. involuntary motion, casts and splints, pathological 45. Select continuous or pulsed fluoroscopy. conditions, contrast agent, or patient’s inability to 46. Document fluoroscopy time. cooperate. 47. Document fluoroscopy dose. 68. Verify accuracy of patient identification on image. 48. Prevent all unnecessary persons from remaining in 69. Evaluate images for diagnostic quality. area during x-ray exposure. 70. Respond appropriately to digital exposure indicator 49. Take appropriate precautions to minimize occupa- values. tional radiation exposure. 71. Determine corrective measures if image is not of diag- 50. Advocate radiation safety and protection. nostic quality and take appropriate action. 51. Describe the potential risk of radiation exposure when 72. Identify image artifacts and make appropriate correc- asked. tions as needed. 52. Wear a personnel monitoring device while on duty. 73. Store and handle image receptor in a manner that will 53. Evaluate individual occupational exposure reports to reduce the possibility of artifact production. determine if values for the reporting period are within 74. Visually inspect, recognize, and report malfunctions established limits. in the imaging unit and accessories. 54. Determine appropriate exposure factors using the 75. Recognize the need for periodic maintenance and eval- following: uation of radiographic equipment affecting image qual- a. Fixed kVp technique chart ity and radiation safety (e.g., shielding, image display b. Variable kVp technique chart monitor, light field, central ray detector calibration). c. Calipers (to determine patient thickness for exposure) 76. Perform routine maintenance on digital equipment d. Anatomically programmed technique including: 55. Select radiographic exposure factors: a. Detector calibration a. Automatic Exposure Control (AEC) b. CR plate erasure b. kVp and mAs (manual) c. Equipment cleanliness 56. Operate radiographic unit and accessories including: d. Test images a. Fixed unit 77. Adapt radiographic and fluoroscopic procedures for b. Mobile unit (portable) patient condition (e.g., age, size, trauma, pathology) 57. Operate fluoroscopic unit and accessories including: and location (e.g., mobile, surgical, isolation). a. Fixed fluoroscopic unit 78. Select appropriate geometric factors (e.g., SID, OID, b. Mobile fluoroscopic unit (C-arm) focal spot size, tube angle). CHAPTER 10 Employment Expectations 223

Position patient, x-ray tube, and image receptor to perform Organizational Structure and Your the following diagnostic examinations: Professional Responsibility 79. Chest 80. Ribs The employer has a right to expect you to use your knowl- 81. Sternum edge and abilities in radiography efficiently and provide 82. Abdomen high-quality service to the patient. In return, you have a 83. Esophagus right to expect the salary and benefits to which you and your 84. Swallowing dysfunction study employer agreed. You should also expect to perform your 85. Upper GI series, single or double contrast job in an environment that is in compliance with safety and 86. Small bowel series public health requirements and free of all forms of harass- 87. Contrast enema (e.g., barium, iodinated), single or ment and discrimination. double contrast You are entering a dynamic and fluid sector of the 88. Surgical cholangiography national economy. Health care advances in diagnosis, 89. ERCP treatment, and delivery are in a constant state of flux. 90. Cystography Funding of health care services is a matter of national 91. Cystourethrography debate. This is the nature of the industry in which you 92. Intravenous urography have chosen to work and build a career. You should expect 93. Retrograde urography to stay abreast of changes in the delivery of health care and 94. Hysterosalpingography remain alert to how such changes affect your employer. 95. Cervical spine/soft tissue neck Remember, issues affecting your employer also affect you 96. Thoracic spine and your coworkers. 97. Scoliosis series Your employer will expect you to function as part of a 98. Lumbar spine team, all of the members of which will be dedicated to the 99. Sacrum/coccyx cost-effective provision of efficient, accurate, and compas- 100. Sacroiliac joints sionate care to the patient. At the same time, the employer 101. Pelvis/hip is the coach of the team and has an obligation to maintain 102. Skull the provision of high-quality service to patients and proper 103. Facial bones accountability to payers. An examination of the expectations 104. Mandible of your employer will reveal your professional responsibili- 105. Zygomatic arch ties are accountable to the five distinct groups described in 106. Temporomandibular joints this chapter. 107. Nasal bones Two primary expectations are common to each of the 108. Orbits five groups. The first expectation is you will provide the 109. Paranasal sinuses highest quality patient care of which you are capable in 110. Toes congruence with what your employer and your profes- 111. Foot sion require. Such patient care is all-encompassing, from 112. Calcaneus providing quality service to the patient, to supporting the 113. Ankle patient’s physical needs, to creating the most diagnos- 114. Tibia/fibula tic images possible. The second expectation is you will 115. Knee/patella respect and accommodate diversity in all of its forms. 116. Femur Such diversity may be linked to culture, language, gen- 117. Fingers der, age, ethnicity, socioeconomics, and the multitude of 118. Hand other unique characteristics that are an integral part of 119. Wrist each person. In health care, we serve patients as they are, 120. Forearm not as we may wish them to be. Our practice of radiogra- 121. Elbow phy must be blind to differences while being caring and 122. Humerus compassionate to all. 123. Shoulder 124. Scapula Expectations of Administrators 125. Clavicle 126. Acromioclavicular joints The administrators of the facility in which you will be 127. Bone survey employed expect you are going to fulfill the job description 128. Long bone measurement associated with an entry-level radiographer. They expect 129. Bone age you to be honest and straightforward with them while pro- Assist radiologist with the following invasive procedures: viding excellent care and service to the patient or customer. 130. Joint injection (arthrography)-fluoroscopic guided High-quality customer service is paramount to your suc- contrast injection cess. It is vital that the patient knows true professionals are 131. Myelography/fluoroscopic guided contrast injection providing care. 224 PART 2 Career Planning

Administrators trust you will speak highly of the facil- the radiologists. This includes not only providing the high- ity and be supportive of its efforts to provide high-quality est quality images of which you are capable but also demon- patient care. You are expected to use professional judg- strating a willingness to resolve personality and work-related ment when using social media, avoiding posting anything conflicts. that may reflect negatively on the institution. You are It is important to determine ahead of time how you wish expected to arrive for work on time and keep absenteeism to be regarded by the physicians. You have a right to be to an absolute minimum. There may be times when you treated respectfully and should take immediate steps to rec- are expected to work extra hours, such as when another tify a situation in which you are being mistreated. At the employee is on vacation or is sick. Administrators are look- same time, the physicians have a right to expect you will ing for employees who are willing to be strong, supportive reciprocate in your professional conduct. team players. Administrators also expect you will be willing to contrib- Expectations of the Radiology Manager ute new ideas for more efficient operation. They assume you will work in harmony with other departments in the facil- The person who is hiring you, the radiology manager, also ity. They may request you serve on committees or perform has a particular set of expectations. This individual is directly other tasks not directly related to radiography. Be the type responsible for your on-the-job performance and overall of employee who exceeds the expectations of administrators, value to the patient or customer and the administration. and you will be well on your way toward establishing the In research I conducted, radiology managers responded to type of reputation that will ensure your success. a survey regarding their expectations of new radiography graduates. Of particular interest are the traits the radiology Expectations of Physicians managers considered most important in an applicant and the areas in which radiology managers have had the most Physicians are customers too. The physicians with whom difficulty with employees after they were hired. you will be working, including radiologists and referring When hiring a new graduate radiographer, 43% of radi- physicians, have their own particular set of expectations. ology managers said knowledge of the technical aspects of Referring physicians expect their orders for radiologic radiography was the most important factor they considered; exams will be carried out as indicated. They expect high- this is a given because the new employee must be able to quality images will be acquired by the radiographers and perform the job. However, 33% responded customer service interpreted properly by the radiologists. Although your skills and interpersonal communication skills were the fac- interactions with these physicians may be minimal, they are tors they most considered when hiring a recent graduate. nevertheless important. These individuals are assuming you know how to perform Referring physicians often come to the radiology the job and expect you will provide excellent service to the department to view images themselves or consult with patient while performing it. This research shows radiology the radiologist. They expect to be treated as professionals. managers have high expectations of you. They expect you They may be unfamiliar with the department and where to know the practice of radiography, deliver quality service supplies are kept. They may be there to perform a proce- to patients, and be capable of establishing positive relation- dure. They expect to be shown where supplies are kept and ships with your coworkers. be assisted as needed. As a professional radiographer, it will A second question inquired about problems radiology be your responsibility to meet or exceed expectations and managers encountered with radiographers on the job. Poor provide high-quality service to the physician as well as the communication skills were identified by 37% as the most patient. significant problem and usual cause for a reprimand or ter- The physicians with whom you will interact most fre- mination. Lack of knowledge of the technical aspects of the quently are the radiologists, and most of this exchange job was cited as the primary reason for a reprimand or termi- will occur during fluoroscopy. The radiologists expect to nation by 36%. In comments entered on the survey, many receive the highest quality images you are capable of pro- radiology managers mentioned attendance problems, tardi- ducing. They will be providing the diagnosis from your ness, lack of dependability, and substance abuse as problems images. Radiologists do not expect to have to ask you to in the workplace that led to reprimands and terminations. reacquire an image you already know is unacceptable. Other areas of concern raised by the radiology managers They do not want to hear excuses for poor images. Radi- included bringing personal problems to work and overall ologists insist you keep them informed about variations lack of initiative. These are problems you should keep out from protocol. They expect you to take an adequate but of your radiography practice. Should any of these issues concise patient history for their use during the interpreta- become matters of personal concern for you, seek coun- tion of the images. seling immediately so that you can bring such problems As a student, you may have had radiographers facilitate under control. Your employer and your patients deserve your interactions with the radiologists. As a new, entry- no less. level radiographer, you now have the responsibility to be Another survey question asked the managers which straightforward and professional during interactions with areas should be most strongly emphasized with student CHAPTER 10 Employment Expectations 225 radiographers as they prepare to enter the workforce. They busy throughout the day, you will find great fulfillment in stressed the following: your work and will likely exceed the radiology manager’s 1. Ongoing technical training expectations. 2. Knowledge of basic nursing skills, such as using IV In a field that changes as rapidly as medical imaging, pumps, taking vital signs, and performing venipuncture your radiology manager will expect you to be knowledge- 3. Ability to work alone without constant supervision able about the newest types of equipment and advances 4. Awareness of the customer’s or patient’s viewpoint in imaging techniques. You are also expected to keep your 5. Strong communication skills skills at a level that allows you to perform all of the dif- 6. Provision of high-quality service with a smile ferent types of radiographic procedures required in your 7. Professionalism in dealing with the public radiology department. On a regular basis, you should 8. Loyalty to the employer review your favorite text on radiographic positioning and 9. Maintenance of clinical skills procedures to refresh your memory and maintain your The radiology managers were asked to rank the factors skills. they considered to have the most positive effect on cus- You have become accustomed to studying, and through- tomer service in their department. The most important fac- out the course of your radiography program, you have had tor (according to 60% of the respondents) was a pleasant to learn how to learn. This process does not end with gradu- and courteous staff. To add to this point, a percentage of ation or passing the certification exam. It is important to Medicare reimbursement is now based on patient satisfac- keep abreast of events in the field by reading the latest radio- tion scores. logic technology journals and textbooks. Textbooks are not Similar to the administrators to whom they report, written solely for students. As a practicing radiographer, you radiology managers expect you to be ready to begin work will want to keep your personal library updated with the on time and to keep absenteeism to a minimum. They are best resources available. counting on you to show up—on time—and provide the Another way to be aware of current developments in highest quality patient care each day you are assigned to the field and exceed your manager’s expectations is to work. Such patient care is expected to be delivered within become an active member of your national and state pro- the scope of practice determined by the profession and in fessional organizations. Both have publications that will full compliance with the standards of ethics and confidenti- bring you the latest news in the profession. In addition, ality of radiologic technology. these organizations need your talents to be successful. As The radiology manager also expects you to conduct a student, you have acquired a store of information and yourself as a professional in your dealings with the patient have developed skill in communicating this knowledge. or customer, the physicians, and your coworkers. You are Take advantage of that momentum, and continue to do expected to be a reliable member of the radiology team. You research in the field. must be flexible and have a positive attitude about handling Most radiology managers will expect you to give some- all the different assignments you may be given in a typical thing back to your profession, which will increase your level workday. of knowledge. Present research papers at state or national The need for balance between the high-touch and high-tech meetings, hold an office in one of the organizations, or offer aspects of radiography is evident. Radiology managers have to help out in planning and conducting a continuing edu- high expectations of new employees. Be prepared to exceed cation meeting. Organizing and conducting an in-service those expectations. Because you are ready to enter the work- education program for your department is a great place to force, you must determine how many of these traits are present begin. If you have never taken part in such activities, this is in your practice already and which ones need additional atten- a perfect time to begin. It does not matter whether you are tion. The managers have carefully described what they need sure about what you are doing; just offer to help or do that and expect. Are you prepared to enter their workplace? first research paper as a graduate. Your radiology manager will expect you to remain busy Meeting and exceeding the radiology manager’s expec- throughout the day. In addition to performing your pri- tations are sure ways to set a course for success in your mary job duties, you may be asked to complete assign- chosen field. Individuals who follow this path derive the ments that do not involve patient care. Quality control most satisfaction from their job and are held in the high- testing or the routine cleaning of imaging equipment or est esteem by their employers. Most important, a commit- lead aprons may be a part of your job responsibility. If ment to excellence in your profession results in healthy you think of your work area as an integral part of your self-esteem, which is reflected in the care and service pro- practice, that sense of ownership will motivate you to care vided to the patients. for it. Slow periods at work may be few and far between; you should take advantage of them whenever they occur. Expectations of Students Under Your Your attitude toward the aspects of your work that do Supervision not involve patient care may determine whether the radiology manager gives you other assignments you may be Your new employer may have students present as part seeking. If you consider lounge areas off limits and keep of an educational program in radiologic technology. The 226 PART 2 Career Planning

employer may be the sponsor of the program or may catheterization laboratory, or physician’s office will probably serve as a clinical site for a program sponsored by another take more energy than you might expect. Establishing your institution. professional relationships will make a world of difference in It may seem ironic that although you are probably read- the satisfaction you receive from your work and your ability ing this as a student still in school, it is already time to con- to provide the level of care you expect of yourself. sider the aspect of future expectations for students. Should Approach your new position as a learner, eager to find you choose to work in an imaging department that serves out all you can regarding routines, protocols, profes- as a clinical site, you will be working with students shortly sional relationships within the work setting, and how the after graduation. This is an awesome responsibility, espe- group functions together. Determine everyone’s level of cially because you will still be in learning mode yourself, responsibility and where you fit in. Your new employer mastering the requirements of a staff radiographer in your expects you will establish professional working relation- new position. ships and conduct yourself with everyone as a member of Working with students is a task to be taken seriously. a tight work unit. You will be expected to avoid gossip, As you already know from your experiences, the students cliques, and any other behavior that inhibits the delivery will expect you to share with them your knowledge of the of high-quality patient care and service. Your employer art and science of imaging and patient care. They will want will expect you are ready to learn all you can from your fair and honest evaluations of their performance. They will coworkers regarding the technical aspects of imaging and want to be treated with the respect due an adult in college, operation of the imaging department or clinic. You and not as another worker, an inexpensive laborer, or someone your coworkers will need to work out personal problems to perform menial tasks. The students under your supervi- as professionals and not allow them to enter the flow of sion will rely on you to help them through the learning the workplace. process. Your coworkers will expect you to come up to speed Whether or not it is part of the orientation to your new quickly and to ask questions when necessary. They will job, seek out the clinical instructor for students in your expect you to conduct yourself as a new graduate, still in department. Find out what is expected of you from the learning mode but ready to assume a high level of respon- educational program. Become thoroughly familiar with the sibility and take on your share of patient care. They will evaluation forms and competency testing forms and system expect you to establish a positive, uplifting relationship you may be expected to use. As a new graduate yourself, with them. They can assist you as you enter the field as a determine whether there is a limit to what role you can play. Learn the specific requirements of direct and indirect supervision of students performing exams and repeat exposures. KEY REVIEW POINTS Consider carefully the legal ramifications of following such Employment Expectations supervisory requirements. As you work with students, remember you are shaping • Skills expected of an entry-level radiographer are outlined in the next generation of radiographers. These individuals the ARRT Task Inventory. will be your coworkers after their graduation. This is a • Advances in diagnosis and treatment are in a constant state key role to play as you become acclimated to the role of of change. • Be honest and straightforward while providing excellent radiographer as well. You have the ability to be a strong care and service to the patient. influence on future professionals in your field. Take the • Speak highly of the facility and be supportive of its efforts to responsibility seriously, and take pride in the impact you provide high-quality patient care. will have on these radiographers who will follow you into • Use social media postings carefully and wisely. the field. • Arrive for work on time; keep absenteeism to a minimum. • Be a strong, supportive team player. • Work in harmony with other departments in the facility. Expectations of Your New Coworkers • Carry out referring physicians’ orders for radiologic exams as written. At the same time you are taking and passing the creden- • Interact professionally with physicians visiting the imaging tialing exam, becoming oriented to a new job, possibly department. • Work with radiologists as fellow team members, providing working with students, and learning your new employer’s them the finest diagnostic images possible. expectations, there will be another very important set of • Make knowledge of technical aspects of radiography, expectations to consider. This area includes your employ- customer service, and communication skills the foundation er’s expectations of your relationship with your new of your practice. coworkers. • Maintain knowledge and skills as imaging procedures change. As a new graduate, you will, in some respects, be like a • Share knowledge and provide direction to students assigned new student all over again. Learning the technical aspects to you. of a new job, even in your chosen field, will take much time • Come up to speed quickly and ask questions of coworkers and energy. At the same time, becoming part of a work group to assimilate into the department. such as a department of radiology, urgent care center, cardiac CHAPTER 10 Employment Expectations 227 professional. Use their experience and knowledge to your There will be expectations from everyone associated with benefit as you deliver patient care. Respond to their help your new position as a graduate radiographer. Meeting by working with them cooperatively, as a new colleague and exceeding those expectations while learning your new and as a professional who is eager to assume a key role in position will create the need to balance all aspects of your their work unit. Exceed your new employer’s expectations radiography practice. In doing so, you will then exceed the by working cooperatively and learning all you can from expectations of your program’s instructors, who first guided your new coworkers. you on your road to success.

Answers to Review Questions

Students: Welcome to my classroom! 15. D. Be familiar with these facts concerning malpractice. Below are the answers to the review questions in the book. 16. D. This means “the thing speaks for itself.” It is some- I have provided rationales where appropriate. The explana- thing that could not have occurred by natural means. tions are written for you in the same way I go over exams in 17. A. Choice 2 is incorrect because a brochure does not my own classes. In most cases, I provide key points regard- have to be given to the patient. Choice 5 is incorrect ing the answer, study suggestions, or both. For other ques- because patients are unlikely to completely under- tions, such as labeled drawings or radiographs, the answers stand all aspects of a procedure. may be obvious and do not require a detailed explanation. 18. B. Choice A is incorrect because a patient who is You will also encounter facts asked in multiple ways, ambulatory would not be on a cart. Choice C is challenging you to think about information from several incorrect because patient care must never be compro- different directions. This will help prepare you for whatever mised because of short staffing. Choice D is incorrect way the questions may be asked on the certification exam because safety is of paramount importance. and will also reinforce the material by causing you to inter- 19. A. It is very important to obtain an accurate patient act with it more than once. In any case, be sure to return history on all patients. to the chapter and use the study outline for detailed review 20. B. Be sure to review the principles of infection control. and to reinforce concepts, facts, and illustrations that need 21. D. your attention. 22. B. Now let’s see if you really know the material. 23. A. Vectors involve animals. 24. B. This differs from vector-borne transmission and Chapter 2 – Patient Care does not involve motor vehicles. 25. B. Choice C would be vector-borne, and choice D 1. D. Be sure to know all of these. would be direct contact. 2. C. MSDS: Material Safety Data Sheets. 26. B. Choice A would be droplet transmission, choice 3. C. Elderly patients tend to be stronger earlier in the C would be vector-borne transmission, and choice D day. would be direct contact. 4. B. Patients who have been held without food should 27. B. Standard precautions were formerly called Univer- be imaged first. sal precautions. 5. C. The need for insulin means patients who are dia- 28. A. Standard precautions are used because we can never betic should be imaged early. know for sure what each patient may carry. 6. B. It is important that either the stomach or the colon 29. D. Handwashing is always the first defense. However, be empty, with nothing interfering from a previous it does not replace any other methods. procedure. 30. A. This is the ideal apparel for these procedures. Head 7. D. Be sure to know these basic legal concepts. D is the and shoe coverings do little, and a regular uniform most complete answer. may carry organisms after the exam is over. 8. B. Choice A is a violation of privacy, choice C is a form 31. C. This precaution is very important to observe. of assault, and choice D is unprofessional behavior 32. A. This greatly increases the chance for a needlestick 9. A. Keep in mind that assault does not have to involve injury and the transmission of pathogens. touching the patient. 33. A. Health care workers must always assume that 10. C. Choices A and D constitute battery. Choice B pathogens are present. Washing per protocol is could be considered false imprisonment. mandatory. 11. A. Although unintentional, it still carries with it pen- 34. B. Handwashing is the best protection against trans- alties. Something that should have been done was not mission of pathogens. done. 35. C. Surgical asepsis is the complete removal of 12. B. The defendant is compared with individuals having organisms. similar experience. 36. A. This is much more complete than medical asepsis. 13. D. The employer is always responsible for the actions 37. B. Always wash hands before beginning any proce- of the employees. This does not mean the radiogra- dure. pher is not also responsible. 38. D. Underarms (because of perspiration), sides, and 14. C. Choice B actually involves loss of life or limb; gross back are considered nonsterile. negligence does not have to involve an actual loss. 39. D.

228 Answers to Review Questions 229

40. B. Droplet transmission involves coughs and sneezes, 63. D. Anaphylaxis is an allergic reaction to foreign pro- direct contact involves a person, and airborne trans- teins, cardiogenic shock results from cardiac failure, mission involves droplets and dust. Radiographers and hypovolemic shock occurs following loss of a must be constantly aware of the methods of trans- large amount of blood or plasma. mission. 64. B. Anaphylaxis is an allergic reaction to foreign pro- 41. D. Standard precautions must be practiced at all teins, cardiogenic shock results from cardiac failure, times. and hypovolemic shock occurs following loss of a 42. D. Note the constant emphasis on handwashing. large amount of blood or plasma. None of the other choices must be followed in every 65. A. Anaphylaxis is an allergic reaction to foreign pro- circumstance. teins. Cardiogenic shock results from cardiac failure, 43. B. Gloves need not be worn with respiratory isolation. hypovolemic shock occurs following loss of a large All of the other choices involve body fluids. amount of blood or plasma, and septic shock occurs 44. D. This prevents the patient from contracting some- when toxins produced during infection cause a dra- thing from the health care worker or the equipment. matic drop in blood pressure. 45. A. Standard precautions is always the most all- 66. D. The radiographer must be able to recognize all of inclusive. these. These types of questions may be on the certi- 46. B. fication exam because patient care in imaging is the 47. C. responsibility of the radiographer. 48. B. Working as a team. 67. B. Keep blood flowing to the brain by placing the 49. C. Great care must be taken when the patient has a patient in the Trendelenburg position, head lower urinary catheter. than the hips. 50. A. 68. C. Choice 2 is incorrect because the patient should 51. D. The radiographer should be constantly observing never be left alone under any circumstances. Choice 3 the patient for any such signs. is incorrect because of potentially devastating conse- 52. D. Choice A is incorrect because it indicates degrees quences; a spinal injury should always be assumed. centigrade. Choice B is incorrect because it indicates a 69. D. Be sure to be familiar with these various devices range of normal temperature in degrees centigrade. that may be present in a patient. 53. D. All are clear liquids. 70. D. Be sure to be familiar with these various devices 54. B. that may be present in a patient. 55. C. This is the real name for a “blood pressure cuff.” 71. A. Nosocomial infections are those acquired in the 56. D. The numerator indicates the blood pressure when health care setting. Most of these infections are the the heart is pumping, the systolic pressure. The result of urinary catheter use. This is similar to a pre- denominator indicates the blood pressure when the vious question but uses the term “nosocomial.” It’s heart is at rest, the diastolic pressure. The symbol important to know both terms. “Hg” stands for mercury. 72. C. The radiographer must be careful working around 57. C. Be certain to flow the oxygen at the proper rate, the ventilator so as to not affect its operation. which is per minute. 73. D. Air is a negative contrast agent. Hence, chest x-ray 58. C. The Heimlich maneuver is performed by a person, exams are contrast studies. For the best contrast the CPR is for cardiac/respiratory arrest, and a nasogastric exposure is made on the second (and deeper) inspira- (NG) tube is for introducing substances directly into tion. Exposure after only one inspiration is an incom- the stomach. plete study. 59. A. The radiographer must always be familiar with the 74. The correct choices are:b, e, f, g. Choice a is incorrect contents of the crash cart and what each item does. because air is a negative contrast agent. Choice c is 60. C. Anaphylaxis is an allergic reaction to foreign incorrect because barium should be mixed with warm proteins, cardiogenic shock results from cardiac water. Choice d is incorrect because nonionic contrast failure, and septic shock occurs when toxins pro- media do contain iodine. duced during infection cause a dramatic drop in 75. D. This is the first and most important issue that must blood pressure. be taken into consideration. Be sure to read the pack- 61. D. Anaphylaxis is an allergic reaction to foreign pro- age inserts that come with contrast agents and review teins, cardiogenic shock results from cardiac failure, the contraindications and side effects. and hypovolemic shock occurs following loss of a 76. A. Extravasation involves escape of the contrast agent large amount of blood or plasma. into the tissues surrounding the injection site. 62. A. Cardiogenic shock results from cardiac failure, 77. D. The radiographer must be aware of all possible hypovolemic shock occurs following loss of a large symptoms and know what to do immediately. amount of blood or plasma, and septic shock occurs 78. B. It is important to remain with the patient and when toxins produced during infection cause a dra- observe for symptoms of a possible reaction. matic drop in blood pressure. 79. B. Maintain composure, yet react quickly. 230 Answers to Review Questions

80. D. This is sometimes confusing, so be sure to review 5. C. Artificial, or human-made, radiation represents and be familiar with it. close to 50% of the total human exposure. 81. A. Special care must be taken when venipuncture is 6. B. performed. Review all of the steps in venipuncture. 7. D. Air kerma is radiation depositing energy at a spe- 82. B. cific point. 83. B. Be familiar with all the items used for venipuncture. 8. A. WR, radiation weighting factor. 84. C. You already know that any list of steps for a pro- 9. A. cedure will begin with washing hands. That immedi- 10. C. This form of scatter has no effect on the image ately rules out choices A and D. As soon as hands are below 70 kVp and does not cause ionization. It is neg- washed, the next step must be gloving. That points ligible above 70 kVp. directly to choice C, which is the only possible answer 11. D. Pair production occurs above 1.02 million electron to this question. Always evaluate the question and volts. read all of the possible answers. Many times you will 12. A. Photoelectric interaction results in absorption of recognize a shortcut such as this. the incident, or incoming, x-ray photon. The differ- 85. A. Venipuncture is part of a radiographer’s scope of ence between this interaction and the rays that pass practice. It is tested on the ARRT exam. It may, how- through the body unaltered to strike the image recep- ever, be regulated by state law in some circumstances. tor is what provides contrast. Compton scatter, with Be sure to know what you can and cannot do on the its resultant fog, certainly affects contrast, but it does job. not produce contrast itself. 86. D. All relevant history and blood values must be pres- 13. B. Compton scatter that is not absorbed by a grid may ent on the chart and consulted before the exam is strike the image receptor and reduce contrast. begun. 14. C. This is also known as classical or Thompson’s scat- 87. A. tering. It has no effect on the image below 70 kVp. It 88. C. is negligible above 70 kVp. 89. C. This may indicate that a reaction is starting. 15. A. This complete deposition of energy results in con- 90. A. The radiographer must respond quickly and be trast being produced on the image. aware that a more severe reaction may be imminent 16. C. No electrons are removed from the atoms being that a more severe reaction may be imminent. struck. 91. B. Understanding of diversity is a prime part of every 17. D. Pair production occurs at megavoltage levels. radiographer’s practice. 18. A. Photoelectric effect occurs as incident photons 92. B. The radiographer should be calling for assistance. deposit their energy in the K-shell. 93. A. Although the other choices may be part of a radiog- 19. B. Compton interaction primarily involves outer shell rapher’s practice in various venues, patient education electrons, wherein both the electron and the photon is always part of practice. scatter, causing the atom to become ionized. 94. B. A cardiac arrest code should be called; CPR should 20. A. The inner shell electron is ejected, becoming a pho- be initiated. toelectron. The atom becomes ionized. 95. B. 21. B. Because Compton interaction causes the produc- 96. C. tion of scatter, a grid is needed to attempt to absorb 97. D. The Rules of Ethics are enforceable by the ARRT. the scatter before it reaches the image receptor. Be certain to understand these for the ARRT exam. 22. B. Compton produces scatter, which during fluoros- 98. B. The Code of Ethics is a set of aspirational goals for copy or mobile procedures may expose the radiogra- radiographers’ practice. pher. Hence a lead apron is required when either one 99. A. Contrast agent reactions can begin with very is performed. benign symptoms. Never leave the patient alone. 23. D. Gyt indicates gray in tissue. 100. B. 24. C. 25. C. Gray indicating absorbed dose, a indicating in air. Chapter 3 - Safety 26. A. Actually, choice B is a good choice as well, but A is more complete. Remember, LET stands for linear 1. B. Natural and artificial background are each approxi- energy transfer. Choice C is incorrect because par- mately 50% of human’s exposure. ticulate radiations deposit more energy than wave 2. D. Radon gas is part of humans’ natural background radiations. Choice D is incorrect because a radiation exposure, which totals 50% of humans’ total exposure. weighting factor is used in the calculation of equiva- 3. D. Earth’s atmosphere and magnetic fields help shield lent dose, not absorbed dose. Keep in mind that the us from cosmic radiation. certification exam will require you to choose the one 4. A. Radon gas may be present in homes, particularly best answer. basements. Special kits should be used to determine 27. C. NCRP reports are the standards on which radia- its presence. tion protection practices are based. Answers to Review Questions 231

28. A. The NRC has the authority to enforce radiation 52. C. The DNA in the cell’s nucleus has been directly protection standards relating to radioactive material. struck by the photons. 29. D. Choice A is not as complete. Choices B and C are 53. B. The master molecule is the DNA in the cell’s incorrect because they imply that there is no risk of nucleus. damage to the individual. 54. C. 30. D. ALARA stands for as low as reasonably achievable. 55. A. The energy is deposited in the cytoplasm, causing 31. D. The effects mentioned in choices A and B are radiolysis to occur, which poisons the cell. This indi- graphically demonstrated on dose-response curves. rectly causes the damage to the cell’s nucleus. 32. B. It is assumed that for every dose of radiation there 56. A. Radiolysis causes the production of hydrogen per- is some response in the organism. This does not mean oxide in the cytoplasm, a poison to the cell. there is damage, just a response. 57. D. Most radiation-induced mutations are recessive. 33. A. Be sure to refer to the illustrations in Chapter 3. 58. A. Free radicals are produced as a result of radiolysis. 34. B. This forms the basis for all radiation protection 59. C. The master molecule is DNA, located in the cel- standards. Be sure to review the dose-response curves lular nucleus. in Chapter 3 and be able to recognize them both from 60. A. This is a result of radiolysis. a diagram and from a written description. 61. D. Because the cellular cytoplasm is so much larger 35. C. The presence of a threshold means that exposures than a cell’s nucleus, it is more likely to be struck by below that level will not cause a response resulting in an incoming x-ray photon. Therefore, statistically certain conditions. For example, certain doses will not speaking, more damage will occur to cells because of cause cataracts. Those doses are below the threshold indirect effect than from the less probable occurrence dose. of direct effect. 36. D. Be sure to review the dose-response curves in 62. B. The Law of Bergonié and Tribondeau states that Chapter 3 and be able to recognize them both from a cells are most radiosensitive when they are immature, diagram and from a written description. undifferentiated, and rapidly dividing. 37. A. Increased dose equals increased probability of 63. B. This law describes cell radiosensitivity. effects, although it does not increase severity of effects. 64. A. This is known as oxygen enhancement ratio (OER). 38. B. Deterministic effects have threshold doses below 65. A. which the effects do not occur. 66. A. The least radiosensitive cells are nerve and muscle 39. A. Note the answer is in millisievert. cells. 40. D. For example, a 29-year-old radiographer could 67. C. Epithelial cells are very radiosensitive. have a cumulative exposure of 29 mSv. 68. B. Ova are more radiosensitive in young girls and after 41. A. This is the dose to remember when you are asked middle age. about radiographers’ annual exposure limit. 69. B. It is important to remember that most somatic 42. A. The same as radiographers’ annual exposure limit. effects of exposure to ionizing radiation do not occur 43. A. at doses used during diagnostic procedures, unless 44. A. This is the same as the annual general public dose repeated procedures are performed at high dose levels. for infrequent exposure. It is always important to practice ALARA. 45. B. 70. A. Genetic effects may occur in the next generation as 46. D. Be sure to master all of the effective dose limits mutations. for occupational exposure and exposure of the general 71. A. Alzheimer disease and Parkinson disease have not public. been linked to radiation exposure. 47. C. The radiation weighting factor takes into account 72. C. the source of exposure, which may be wave or particu- 73. A. Gonadal shields may reduce exposure to males by late, and the actual amount of energy deposited per up to 95%. unit length of tissue—the LET (linear energy transfer). 74. B. Use of low-mAs, high-kVp techniques always 48. A. The amount of energy deposited in tissues is results in a lower patient dose. Focal-spot size is not directly responsible for any biologic damage that may related to patient dose. occur. 75. C. The other choices all result in increased dose to the 49. C. Relative biologic effectiveness. patient. 50. D. Remember that the cellular life cycle always begins 76. C. These are the three basic methods for providing with interphase. The reason D is the correct answer is optimal radiation protection. because the three steps in interphase are listed in their 77. C. TLDs and film badges are used for personnel mea- proper order. This makes choice D a better answer surement, whereas a Geiger-Mueller detector is used than choice B. to detect the location of a specific source of radiation 51. D. Choice A defines cell division for somatic cells such as a radionuclide. only. 78. B. 232 Answers to Review Questions

79. B. Metal and plastic filters are incorporated into the 99. D. It is also known by its abbreviation of PBL. film badge case. 100. D. Choices A, B, and C are all reasons filtration is 80. C. This is the monitor of choice to be used when sur- used; however, filtration should never be adjusted veying radiation dose in a fluoroscopic installation. by the radiographer. A qualified radiation physicist The TLD and film badge are used for personal moni- should be the only person adjusting x-ray beam toring, and the Geiger-Mueller detector surveys for filtration. radioactive particles. 81. D. Chapter 4 – Image Production – 82. A. X-ray Equipment Operation 83. D. The TLD and film badge are not digital and are used to measure personal dose. 1. B. Most views required by the radiologist are acquired 84. A. The optically stimulated luminescent dosimeter digitally during fluoroscopy. may also be used up to 3 months. 2. B. The atom may be broken down into subatomic 85. B. The film badge is sensitive to extremes in tempera- particles but they would not have the characteristics ture and humidity. It is being phased out of use. of the element. 86. C. MMD stands for mean marrow dose. 3. C. The information acquired must be converted from 87. A. GSD stands for genetically significant dose. its analog form to digital for further manipulation. 88. D. Choice A is incorrect because the timer must 4. D. Photons may also be called quanta. sound an alarm after 300 seconds (5 minutes). Choice 5. A. Atomic number is the number of protons. Protons B is incorrect because the purpose of the alarm is to and neutrons are contained in the atomic nucleus. sound an alert. Choice C is incorrect because the 6. C. The AEC is calibrated to provide the images most alarm sounds after 5 minutes. preferred by the radiologists. 89. D. This is one of the three cardinal principles of radia- 7. D. Hence, the exposure time when using an AEC is tion protection; the others are time and shielding. very dependent on the kVp. 90. B. This problem is different from many you have been 8. D. The falling load generator makes use of the maxi- asked: you are being given the new dose and asked mum heat storage capacity at every mA and time to figure out what the new distance should be. You combination. This allows for the shortest exposure should not need to use an equation on paper or a cal- time possible. culator to solve this problem. The question wants you 9. A. This necessitates the use of a rectifier to change AC to reduce your dose to ¼ the amount you receive at a to DC. distance of 2 feet. Keeping in mind the inverse square 10. B. The octet rule states that no more than eight elec- law, you may recall that doubling distance causes the trons can be in the outer shell. It does not stipulate dose to drop to ¼. Therefore the correct answer would that there must be eight electrons in the outer shell. be to step back to a distance of 4 feet from the table. 11. B. Particulate radiations are highly ionizing. Choice A implies that you need to quadruple your dis- 12. A. Because it has mass, particulate radiation may tance from the table to reduce the dose to ¼. Choice travel along different paths. D would result in a decrease in dose because of shield- 13. D. ing but not the specific reduction in dose mentioned 14. C. Do not be fooled by choices that use different units in the problem. of measurement. Light speed is expressed in miles per 91. D. This thickness is the minimum that must be worn; second, not miles per hour. 0.5-mm lead equivalent should be worn. This is tricky 15. A. and is used here to make the point that careful reading 16. D. Wavelength can be measured from crest to crest or of the question is very important. trough to trough. 92. C. Choice A is incorrect because holding patients 17. B. Higher-frequency waves have shorter wavelengths; should never be routine. Choice B is incorrect because lower-frequency waves have longer wavelengths. a radiographer should be the last choice to hold the 18. D. The speed of x-ray travel is constant, regardless of patient. Choice D is incorrect because routinely using the factors used to produce them. student radiographers is unacceptable in practice. 19. B. 93. A. 20. B. Attenuation means that the x-rays may be absorbed 94. B. Hence this is the best place to stand whenever pos- or scattered. sible, when necessary. 21. C. Be certain to review the inverse square law; always 95. A. remember the inverse square relationship. The result- 96. B. Dose area product meter ing answer cannot be double or half; it will be ¼ or 97. C. The OSL dosimeter is most sensitive, followed by 4 times. the TLD and film badge. 22. C. Energy cannot be created or destroyed, only 98. B. changed in form. The energy is merely transferred. Answers to Review Questions 233

23. A, D. You may encounter some questions in this format. 49. A. High-speed anodes spin from 10,000 to 12,000 24. A, B, C, E, G, H. rotations per minute (rpm). 25. D. Electromagnetic induction does not require that 50. D. This type of generator allows extremely short expo- two conductors touch each other. sure times. 26. B. Self-induction occurs in the autotransformer; 51. A. These are the x-rays produced by two types of inter- mutual induction occurs in the step-up and step- actions that occur between incident electrons from down transformers. the cathode and the tungsten atoms of the anode. 27. B. Mutual induction occurs in the step-up and step- 52. D. This is where voltage is boosted to kilovoltage down transformers. levels. 28. B. This intensifies the magnetic fields, making the 53. C. The ionization chamber is located between the transformers more efficient. patient and the image receptor. Phototimers are sel- 29. C. A generator at the power company converts dom used. mechanical energy to electrical energy. A motor con- 54. D. Coupled with an electronic timer, this results in 1 verts electrical energy to mechanical energy. times as short as ⁄1000 second. 30. C. 60 Hertz means 60 cycles per second. The voltage 55. A. Pressing the rotor button activates a motor that may be 110 or 220. turns the anode. It also begins thermionic emission at 31. A. 60 cycles per second results in 120 pulses per sec- the cathode. ond because it cycles back and forth 120 times per 56. C. The ionization chamber is a wafer-thin chamber second. containing gas that is ionized by the x-rays passing 32. B. Such a low ripple means higher average photon through it. At a predetermined level of ionization, the energy. High frequency is very efficient. exposure is terminated. 33. C. Three-phase power produces higher average pho- 57. A. The machine keeps the filament warm between ton energy than single-phase power. exposures. 34. B. The autotransformer is a variable transformer that 58. B. Each time the rotor is activated, thermionic emis- operates on the principle of self-induction. sion begins to occur at the filament. This heating of 35. A. Voltage is stepped up while current is stepped the filament causes tungsten to evaporate, thus slowly down in the same proportion. A transformer is named deteriorating the filament. for what it does to voltage. 59. B. Choice C is incorrect, although many first-year 36. C. The voltage is varied at the autotransformer, then students experience this activity when technologists boosted to kilovoltage levels by the step-up transformer. try to hurry them from the room! Choices A and D 37. D. Older x-ray machines require that the line volt- are incorrect because unnecessarily heating the fila- age compensator be adjusted manually, whereas newer ment actually reduces x-ray tube life. equipment lets the machine do the adjustment itself. 60. D. This causes a space charge or electron cloud to 38. A. A transformer is named for what it does to voltage. form around the filament. 39. C. Thermionic emission is the boiling off of electrons 61. B. Voltage is the force behind the movement of elec- from the filament wire. trons in a circuit. 40. D. The kVp meter indicates what the voltage will be 62. B. This is primarily a result of bremsstrahlung interac- after being stepped up. Hence it is prereading. tions at the anode. 41. A. The step-down transformer is located in the fila- 63. C. X-rays and heat are produced at the anode. This ment circuit. is the result of a massive energy conversion in which 1 42. D. The timer is accurate as low as ⁄1000 of a second more than 99% of the incident electrons’ kinetic (which is 1 ms or 0.001 second). energy is converted to heat energy, while less than 1% 43. B. The rectifier changes incoming alternating current is converted to x-ray energy. This is a clear example from the power company into direct current for use of the law of conservation of energy. No light is pro- by the x-ray tube. duced in the x-ray tube. 44. C. The filament and focusing cup are part of the cath- 64. C. As incident electrons fly past the atomic nuclei, ode assembly. The focusing cup has a negative charge they are slowed, causing the production of heat and at the moment of exposure so as to repel the electrons x-rays by bremsstrahlung. X-rays are also produced by from the cathode. the characteristic interaction. 45. B. The rectifier changes AC to DC. 65. A. As incident electrons dislodge K-shell electrons in 46. D. Most equipment uses an electronic timer. the target material, outer shell electrons fall inward 47. B. At this point, AC is changed to DC so that cur- to fill the holes. This causes the release of energy in rent is flowing in only one direction through the x-ray the form of x-rays, with energy characteristic of the tube. difference in energy levels between the K-shell and 48. B. Current is the flow of electrons, as measured in L-shell. milliamperes (mA). Hence the mA meter provides 66. C. More than 99% of the energy is converted to heat. the reading. 67. B, C, D, G, H, J. 234 Answers to Review Questions

68. D. Choice A is correct in stating that the x-ray beam 86. B. is heterogeneous, but the second half of choice A is 87. C. Be sure to review these quality control standards incorrect. before you take the certification exam. 69. C. We do not often discuss the x-ray beam in this 88. D. Some sources state accuracy within 4-6 kVp. Be detail, but be sure to review discrete and continuous in sure to review these quality control standards before Chapter 3. you take the certification exam. 70. A. Choice B is incorrect because soft rays have long 89. D. Be sure to review these quality control standards wavelengths. Choice C is true, but it is not the pri- before you take the certification exam. mary purpose of filtration. Choice D is incorrect 90. B. Be sure to review these quality control standards because long-wavelength rays are called soft rays. before you take the certification exam. 71. B. We more commonly discuss beam quality using the 91. B. It is measured in-air at the tabletop. term half-value layer. Regardless of the fraction, it is 92. B. Automatic brightness control always the amount of material needed to reduce beam 93. D. Be sure to review these quality control standards intensity to that level. before you take the certification exam. 72. D. These are detailed statements attempting to 94. A. Be sure to review these quality control standards define the amount of filtration required. D is the before you take the certification exam. most complete and accurate of all the choices. A is 95. B. Be sure to review these quality control standards incorrect as to amount, B is incorrect because we before you take the certification exam. cannot remove all soft rays from the beam, and C 96. C. Be sure to review these quality control standards is incorrect because compensating filtration is added before you take the certification exam. only for certain exams. 97. A. This provides for actually radiographing an object. 73. D. Fill-in questions may be used on the certification 98. B. Note that this question is asking the amount of mA exam, although they probably will not have three actually used and not the setting of the mA on the blanks like this one. Although we do not often deal control panel. with heat units, be sure to review the constants used 99. C. Choices A, B, and D are also marks on the focal in heat unit production. track, but they are caused by malfunctions. 74. D. kVp must be within plus or minus 10% of what 100. A. Representatives of The Joint Commission (TJC) is set. Be aware that some sources set the range from regularly visit health care facilities to examine docu- 4-6 kVp. mentation of compliance with quality control and 75. D. quality assurance standards. 76. A. This is where the electronic image again becomes visible. Chapter 4 – Image Production – 77. B. The electrons are then accelerated toward the out- Digital Image Acquisition put phosphor. 78. C. This is the point where the rays exiting the 1. B. Dose area product patient strike the input phosphor and it glows with 2. A. visible light, releasing electrons from the photo- 3. B. mAs controls the electrons flowing through the x-ray cathode. tube and striking the anode. Therefore it directly con- 79. A. This is the equation used to calculate total bright- trols the number of x-rays produced. In digital imag- ness gain. ing, brightness may be manipulated using window 80. D. Although A, B, and C are all good answers, remem- level. ber that we need to choose the one best answer, which 4. A. Whatever is changed in mAs directly impacts recep- is D. You are not likely to encounter this type of word- tor exposure. ing, but this question is a good exercise to remind you 5. C. mAs controls the electrons flowing through the to look for the one best answer. x-ray tube and striking the anode. Therefore it directly 81. A. 13% ripple direct current, not alternating current. controls the number of x-rays produced. Three-phase, 12-pulse produces ripple as low as 4%. 6. C. Single-phase ripple is 100%. 7. B. Photostimulable phosphor. 82. B. Three-phase, six-pulse produces ripple as low as 8. D. mAs is a quantitative factor. 13%. Single-phase ripple is 100%. 9. D. 83. D. This is why the formula for heat units for three- 10. D. kVp controls the wavelength and penetrating ability phase, six-pulse equipment is multiplied by 1.35. of the beam. In digital imaging window width can be 84. B. This is why the formula for calculating heat units used to manipulate contrast. for three-phase, 12-pulse equipment is multiplied by 11. B. It is governed by the 15% rule. 1.41. 12. A. 85. C. This question asks for two answers; be sure you 13. A, B, D. Think about each answer individually before know what is meant by each term. answering this question. Answers to Review Questions 235

14. B. The use of the 15% rule to increase kVp results 50. B. But erasing daily is better and preferred. in double the density. In equal receptor exposure as 51. A. doubling mAs. 52. A. However, smoothing may negatively impact resolu- 15. C. tion. 16. D. This is another way of asking about the inverse 53. A. Detection of collimated edges is crucial to obtaining square law. an accurate histogram. 17. A. 54. D. This is in congruence with ALARA. 18. B, C, E, F. These factors all impact the geometry of the 55. A. image. 56. D. 19. B. The monitor must be high resolution. 57. C. Technologists’ monitors are not usually high defini- 20. A. tion (HD). 21. B. 58. D. Total exposure reaching the IR 22. D. Overall, the beam is harder so contrast may be 59. D. lower. 60. B. This enhances visibility of detail. 23. C. 61. A. This may allow for higher kVp and lower mAs, 24. B. Due to a change in SID resulting from the tube which causes an increase in quantum mottle or noise. angle 62. C. More total exposure is required to produce a useable 25. C. The intensity of the x-ray beam is actually a little image. higher toward the cathode side of the tube. 63. C. 26. B. Anode heel effect 64. A. The more the image is processed the greater the 27. D. Without contrast, produced by differential absorp- opportunity for image degradation. tion of the x-ray beam, detail cannot be visible. 65. B. There is a greater difference between the signal and 28. A. any noise that may be present. 29. D. This is the space from center to center of adjacent 66. A. pixels. 67. C. 30. C, E, F. 68. C. Expressed as H/D. Did you notice how choice B 31. A, B, D. This is the opposite of question 30. tried to get your attention? Be sure to read the entire 32. B. answer. 33. D. Photoelectric interaction results in absorption of 69. D. incoming photons. It is also very influenced by the 70. A, B, F. Keep in mind that grids are used over part atomic number, not atomic mass, of anatomic structures. thickness of 10 cm; the grid conversion factors are used 34. D. Compton interactions produce scatter, which causes to change mAs, not kVp; and grids do not prevent the contrast to decrease. production of scatter, they just try to absorb it after it 35. D. Rays that have been removed from the beam must has been produced. be restored by increasing mAs. The area being irradi- 71. B. These grids can be used only within a certain range ated still remains smaller. of SIDs, as stated on the label on the grid. 36. D. Many of the scatter photons are being absorbed by 72. D. Using a focused grid outside of its grid radius will the grid, resulting in higher contrast. result in grid cutoff. 37. C. The overall wavelength of the beam is shorter, result- 73. C. But crosshatch grids prevent angling of the tube and ing in lower contrast. are extremely susceptible to grid cutoff. 38. D. 74. B. Choice A is incorrect because decreased density in 39. D. Controlled by SID, OID, focal-spot size, pixel pitch the middle would not be caused by use of an inverted 40. A, D, F. parallel grid. Choice C is incorrect because den- 41. B. Pixel pitch is very important to detail in digital sity would decrease in the middle of this radiograph. imaging. Choice D is incorrect because density could decrease 42. B. across the entire radiograph, depending on how the 43. A. Choices B, C, and D are all examples of distortion. grid has been positioned. 44. B. 75. A. The grid conversion factor or Bucky factor for a 12:1 45. B. The optimum conditions are longer SID and shorter grid is 5 times the original mAs. OID. 76. D. Even though not used much anymore, it is particu- 46. D. This results in the part appearing shorter than it larly effective on lateral cervical spine radiographs. really is. 77. D. Technique charts are generally not needed for exams 47. A. This results in the part appearing longer than it when AECs are used. really is. 78. D. Automatic exposure controls are set to terminate 48. B. Digital imaging takes into account the total dose to the exposure after a certain amount of radiation has the patient. passed through the ionization chamber. Consequently, 49. C. changes in kVp will have no effect on receptor exposure. 236 Answers to Review Questions

Some effect on contrast may occur if the change in kVp 9. B. Reread each of the other choices carefully, and you is substantial. will see that this is the one best answer. Other choices The following answers relate to terminology used in digital have certain valid points, but only this one covers the imaging. Be certain to review these basic concepts. Keep in most important aspects of pediatric radiography. mind the ARRT exam will not ask questions related to specific 10. C. Although choices A and B are certainly valid, brands of equipment made by various manufacturers. There- choice C takes precedence over all the others. Choice fore, the concepts tested should be broad in nature, similar D is incorrect because the radiographer may take to these questions. additional projections as needed. 79. B. 11. D. Choice A is incorrect because it does not mention 80. C. that a physician has approved such removal. Choice B 81. B. is incorrect because it is not necessary for a radiologist 82. D. to provide the order. Choice C is incorrect because the 83. B. patient’s attending physician may direct that the collar 84. B. be removed. 85. B. 12. A. This plane divides the body into superior and infe- 86. C. rior portions. 87. B. 13. C. This plane divides the body into equal right and 88. D. left portions. 89. B. 14. A. A transverse plane passes crosswise through the 90. B. body at right angles to its longitudinal axis. 91. A. Modulation transfer function 15. B. This plane divides the body into anterior and pos- 92. D. terior portions. 93. D. 16. D. This plane would still divide the body into right 94. B. Picture element and left portions, but they would be unequal. 95. A. 17. A. A ball-and-socket joint has a rounded head of one 96. C. base moving in a cuplike cavity; it is capable of move- 97. B. ment in an infinite number of axes. 98. A. 18. A. The primary example is the hip. Do you see how 99. B. questions can be worded differently to ask for basi- 100. A. cally the same information? Reread questions 17 and 18. Be sure to really know what you are studying, so Chapter 5 - Procedures you can choose the correct answer no matter how the question is worded. 1. D. Be sure you can identify each body habitus by 19. C. An example of a hinge joint is the elbow. Do you see word description and by diagram. Review them in why patients with elbow injuries are in so much pain? Chapter 5. Any movement whatsoever causes great discomfort. 2. A. Be sure you can identify each body habitus by 20. D. Motions can be flexion, extension, adduction, and word description and by diagram. Review them in abduction; an example is the carpometacarpal joint of Chapter 5. the thumb. 3. D. Be sure you can identify each body habitus by 21. B. An example of this type of joint is the proximal word description and by diagram. Review them in radioulnar articulation. Chapter 5. 22. B. These two may not necessarily be AP and lateral. 4. C. Be sure you can identify each body habitus by The important point is the part may be viewed from word description and by diagram. Review them in two angles 90 degrees to one another. Chapter 5. 23. D. This allows for maximum visualization of the lower 5. B. Be sure you can identify each body habitus by ribs. word description and by diagram. Review them in 24. A. All of the answers are valid. Be sure to know at least Chapter 5. the basic points regarding arthrography, even though 6. A. Be sure you can identify each body habitus by it is gradually being replaced by MRI. word description and by diagram. Review them in 25. D. Choice 1 is incorrect when cervical myelography Chapter 5. is performed. Choice 2 is incorrect because contrast 7. D. Be sure you can identify each body habitus by agents used in myelography are water soluble. Choice word description and by diagram. Review them in 4 is incorrect because gravity is used to distribute the Chapter 5. contrast medium. Choice 5 is incorrect when lumbar 8. A. Be sure you can identify each body habitus by myelography is performed. Be sure to know at least word description and by diagram. Review them in the basic points regarding myelography, even though Chapter 5. it is gradually being replaced by MRI. Answers to Review Questions 237

26. A. Intravenous urography is gradually being replaced Choice 4 is incorrect because the central ray enters the by CT. foot at the base of the fifth metatarsal. 27. B. Notice how similar choices A and B are. Read care- 43. B. Choice 2 is incorrect because this rotates the ankle fully, and then choose only the correct answer. too far. Choice 3 is incorrect because rotation should 28. A. Choice B is incorrect because the ulnar surface is in be adjusted 15 to 20 degrees for the mortise joint. contact with the film. Choice C is incomplete; parallel Choice 4 is incorrect because rotation should be at 45 with what? Choice D is incorrect, because using the degrees for the bony structure. fastest imaging system is not imperative. 44. D. Choice 3 is incorrect because the patient should be 29. C. Choice 2 is incorrect because the thumb should be rolled toward the affected side. Choice 6 is incorrect up. Choice 4 is incorrect because the elbow should be because the fibula should appear posterior to the tibia flexed 90 degrees. Choice 5 is incorrect because the on the radiograph. central ray should be directed to the midpoint of the 45. C. Choice 3 is incorrect because the patella must forearm. be perpendicular to the IR. Choice 4 is incorrect 30. B. Choice 1 is incorrect because the forearm and because the central ray should be directed 5 degrees humerus should be in the same plane. Choice 4 is cephalad. incorrect because the hand must be supinated. 46. A. All of these conditions are needed for an accurate 31. A. Choice 1 is incorrect because the hand is not pro- study of the patella in the tangential projection. nated. Choice 4 is incorrect because the arm may be 47. D. Choice A is the opposite of the correct answer. slightly abducted. Notice the difference one letter Choice B is incorrect; both joints should be included. can make in a medical term (adducted vs. abducted). Choice C is incorrect; the patient should be supine. Read carefully. 48. D. Direction of the central ray for some projections 32. C. Choice 2 is incorrect because no angle is put on the can be very specific. Notice how similar the choices central ray. Choice 4 is incorrect because respiration are for this question. Be sure to know central ray should be suspended. directions for all major projections. 33. B. Choice A is incorrect because it would not be 49. B. Hangman’s fracture is caused by acute hyperexten- appropriate to double-expose the IR. You may put sion of the head on the neck; the arch of C2 is frac- both joints on one IR, but not both joints with tured and there is anterior subluxation of C2 onto C3. and without weights. Choice C is incorrect because 50. B. Note the opposite way of asking question 49. Be both joints may not necessarily be placed on the prepared for questions to be asked either way. same IR. Choice D is incorrect because the patient 51. D. Such patients require special care and handling should be standing, if possible, and respiration while positioning. Let them take it at their own speed. must be suspended. 52. C. The pars articularis is between the superior and 34. D. Choice 1 is incorrect because an AP projection is inferior articular processes of a vertebra. commonly used to radiograph the clavicle. PA may be 53. A. Any cervical injury must be handled with the used, but it is not mandatory. Choice 2 is incorrect utmost care. because the direction of tube angle in the PA axial 54. B. Choice 4 is incorrect because the lateral projection projection should be caudad. of the cervical spine is always taken with the cervi- 35. A. Choice 2 is incorrect because the affected scapula cal collar in place until the finished image has been should be centered to the IR. cleared by a physician. Choice 5 is incorrect because it 36. D. Be sure to review all of the fractures listed in the would distort the image. chapter. 55. C. Choice 2 is incorrect because no angulation is 37. A. Be sure to review all of the fractures listed in the placed on the central ray. Why not a falling load gen- chapter. erator? It is not possible on such a machine to get 38. C. This is characterized by degeneration of one or sev- long exposure times, which you want to have for the eral joints. The patient is likely to be in great discom- “breathing technique” used for a lateral projection of fort. the thoracic spine. If all generators in a department 39. B. A giant cell myeloma is a type of tumor that is easy are the falling load type, you must do the best you to penetrate. can. Little blurring will occur, however, because the 40. C. These patients require slow and careful handling. exposure time is so short. 41. B. Choice 2 is incorrect because the plantar sur- 56. D. Choice 2 is incorrect because the hips and knees face rests on the IR. Choice 4 is incorrect because should be flexed. the central ray is directed to the base of the third 57. C. Choice A is the opposite of the correct answer. metatarsal. Choice B is incorrect; the part should be elevated 25 42. A. Choice 2 is incorrect because the plantar surface to 30 degrees from the table. Choice D is incorrect; of the foot should be perpendicular to the cassette. there is no angle on the central ray. 238 Answers to Review Questions

58. A. Be sure to keep the central ray paths clear among 75. D. However, there are still situations where the radiog- all the projections you have learned. rapher may be called upon to perform skull imaging 59. D. Emphysema is a condition in which air is trapped using conventional positioning. in the alveoli, which hyperinflates the lungs and 76. C. Choice B is incorrect because of the degree of makes them much easier for x-rays to penetrate. angulation. Choice D is incorrect because it indicates 60. A. There is a fine line between just learning medical that the head is resting on the nose. terminology and knowing something about patho- 77. A. Read choices B, C, and D carefully and note that logic conditions. Be sure to review the major patho- only one or two words are different from those in the logic conditions presented in this chapter. Pathology correct answer. It is not likely that the questions on is on the ARRT exam. the certification exam will have answers this similar. 61. D. This is another way to ask about emphysema. The question is worded this way to help you really sort 62. D. Because emphysema makes the lungs so easy to out the specific details of this projection. How did you penetrate, automatic exposure controls sometimes do? Do you see why choice A is correct? cannot shut off fast enough, which causes the film to 78. D. Choices A and B are clearly incorrect because this be too dense. is a submentovertical projection. Choices C and D 63. B. Even if you are not sure about an answer, this one is differ only in the perpendicular versus parallel place- a good example of how to narrow your choices. Notice ment of the IOML. the similarity between the word “bronchial” in the 79. C. Whereas the Waters projection also shows all of stem of the question and the word “bronchogenic” in the paranasal sinuses, the upright projection will best choice B. If you encounter questions about which you indicate fluid levels. are not totally sure, look for such similarities. In many 80. C. This will be demonstrated during an upper GI cases they will lead you to the correct answer. series. 64. C. These letters stand for chronic obstructive pulmo- 81. D. Intestinal obstructions are sometimes difficult to nary disease. image properly because the obstruction may be more 65. A. Choice 2 is incorrect because the shoulders should difficult to penetrate while the backed-up gas may be be rotated anteriorly, moving the scapulae out of the quite easy to penetrate. Again, using a manual tech- field of the ribs. Choice 4 is incorrect because respira- nique may be beneficial. tion should be on full inspiration. 82. B. Other portions of the bowel may be perfectly 66. C. Choice A is incorrect because the body should be normal. These patients are usually in some degree of rotated only 15 to 20 degrees. Choice B is incorrect discomfort. because this is an anterior oblique. Choice D is incor- 83. D. Bowel obstructions make the patient extremely rect because breathing causes a blurring of lung detail. ill and uncomfortable. Consider using a manual A falling load generator should not be used because it technique. inhibits the ability to use long exposure times that run 84. A. This form of cancer requires immediate interven- several seconds. tion. Being familiar with the various pathologic con- 67. B. Choice A is incorrect because a PA projection causes ditions you will encounter makes radiography that superimposition of the spine and a lateral projection is much more interesting. Look up any conditions with not possible. Choice C is incorrect because respiration which you are unfamiliar. should be suspended. Choice D is incorrect because 85. C. The other conditions are all in the bowel. an AP projection would increase magnification. 86. D. This condition is characterized by large amounts of 68. D. Rickets is a condition that is easy to penetrate. gas; use care when choosing the exposure technique. 69. B. Paget’s disease is a nonmetabolic bone disease. 87. A. Patients with diverticula may be nearly asymptom- 70. C. Osteoporosis is very easy to penetrate. Manual tech- atic or in great discomfort. nique should be used if possible. An AEC often can- 88. C. This condition may be characterized by projectile not terminate the exposure fast enough, resulting in an vomiting. Have emesis basins at hand. overexposed image. Be knowledgeable about manual 89. B. This is a very painful condition for the patient. techniques you may use in these types of situations. Work quickly. 71. A. Hydrocephalus is harder to penetrate. 90. B. Take careful note of the degree and direction of 72. C. These patients may be frail and brittle. Be sure to rotation. take your time with them. 91. D. This is the most accurate and complete answer. 73. D. D is the more complete answer when compared The others are incomplete. with choice C. There is no angle on the central ray. 92. C. Because this is an LPO, the patient must be supine. 74. B. Be sure to read carefully and distinguish between That rules out choices A and D. parallel and perpendicular. Even though head radiog- 93. A. Choices B and D can immediately be eliminated raphy has been largely replaced by computed tomog- because they place the patient prone. A lateral raphy, basic skull positioning may still appear on the decubitus position requires the patient to be lying Registry exam. on the side. Answers to Review Questions 239

94. C. This stands forendoscopic retrograde cholangiopan- 12. A. Be sure to review stochastic and deterministic. creatography. The severity, not the probability, of deterministic 95. D. These are harder to penetrate. effects increases with increased dose. Direct effect 96. C. Wilms’ tumor is seen primarily in children. and indirect effect differentiate whether the initial 97. A. PKD is harder to penetrate. ionizing event occurs on the most radiosensitive mol- 98. C. Wilms’ tumor is harder to penetrate. ecule (direct effect) or on another molecule (indirect 99. B. Patients are typically in extreme pain. effect). 100. C. Questions on RPO and LPO kidneys tend to 13. A. Occupational cumulative exposure is determined be confusing because it is hard to remember which by multiplying years of age times 10 mSv. Study tip: kidney ends up perpendicular or parallel. Be sure to Be sure to read each choice carefully and entirely review these projections. before choosing an answer. 14. D. This limit is important to keep in mind when con- Chapter 6 – Challenge Tests – sidering ALARA. Test #1 15. D. Lead, not aluminum, equivalent will absorb most of the scatter radiation energy. Because the secondary Answers to Challenge Test Number 1 barrier is located where only scatter or leakage occur, 1 1. B. These changes may include absorption and scatter ⁄32-inch lead equivalent is sufficient. Primary barriers 1 radiation. Radiation that emerges from the patient is require ⁄16-inch lead equivalent. called exit radiation. 16. C. Photons lose considerable energy after scattering. 2. C. Photoelectric interaction produces contrast as a 17. A. The dose is determined by the inverse square law. result of the differential absorption of the incoming The distance was halved; therefore, the dose went up x-ray photons in the body’s tissues. X-rays are com- 4 times (not 2 times). pletely absorbed in some areas of the patient. Choices 18. A. The minimum source-to-skin distance for fixed A and B are types of scattering. Pair production does fluoroscopes is 15 inches; for portable fluoroscopes, not occur in radiography. 12 inches (although 15 inches is preferred). Be sure to 3. A. Compton interaction produces scattered photons review these required distances. that emerge from the patient in divergent paths and 19. A. Gonadal shielding is even more effective for males, may expose the radiographer or radiologist. The pho- reducing the gonad dose by up to 95%. toelectric effect is responsible for total absorption of the 20. D. Target theory states that for a cell to die after radia- incoming x-ray photon during attenuation. Coherent tion exposure, its master, or target, molecule (DNA) scattering and pair production occur when x-ray ener- must be inactivated. Direct effect occurs when radia- gies are beyond the moderate range used in radiography. tion transfers its energy directly to the DNA. The 4. B. This stands for Gray in-air. doubling dose is the dose of radiation necessary to 5. A. produce twice the frequency of genetic mutations as 6. C. would have occurred in the absence of the radiation. 7. D. LET varies because of different levels of ioniza- Be sure to review these concepts. tion. It occurs with high-ionization radiations, such 21. B. The dose equivalent at which blood count is as neutrons and alpha particles, and during x-ray and depressed is much higher than diagnostic levels but gamma-ray procedures. may occur during radiation therapy or interventional 8. D. The becquerel measures the quantity of radioactive procedures. material. 22. D. This is the definition of free radicals, which can 9. C. This describes a dose-response curve, such as linear- cause biological damage to the cell. Some free radicals nonthreshold. may chemically combine to form hydrogen peroxide. 10. B. Medical x-rays are an artificial source of ionizing Radiolysis results in an ion pair in the cell: a positively radiation; diagnostic procedures account for the larg- charged water molecule and a free electron. est source of artificial radiation exposure to humans. 23. D. According to target theory, substantial research Natural background radiation is that contained in the indicates that DNA, contained in the cellular nucleus, environment. is the master molecule. Hydrogen peroxide is a poi- 11. A. There is a definite safe, or threshold, dose at which son that can cause damage to the cell. A free radical cataractogenesis does not occur. Choice C does not is a highly reactive ion with unpaired electrons in the make logical sense because the question states that outer shell. RNA transmits genetic instructions from cataractogenesis does not occur at low levels of radia- the nucleus to the cytoplasm of the cell. tion exposure. Occupational dose is the amount of 24. A. Cytogenesis refers to the origin and development of radiation to which radiographers are exposed. Study cells. Spermatogenesis is the development of spermato- tip: When there are opposite choices (e.g., threshold zoa. Organogenesis refers to the formation and differ- and nonthreshold), one of them is usually the correct entiation of organs during embryonic development. answer. Germ cell division is called meiosis. 240 Answers to Review Questions

25. D. Although all of these effects may occur, the most 42. B. The primary protective barrier in the wall extends common result of LET is no effect. However, ALARA from the floor to a height of 7 feet. must still be practiced. 43. A. This accounts for the largest increase in radiation 26. C. Adult nerve tissue and even immature cells, which exposure since 1980. are very radiosensitive, require doses of radiation 44. D. Mitosis describes division of somatic cells. higher than those used in medical diagnostic proce- 45. A. Although there are several reasons for using colli- dures, although ALARA must still be practiced. mation and gonadal shielding, the single most impor- 27. D. Such doses still pose a risk to the embryo-fetus, so tant is to attempt to keep mutations from occurring. ALARA must still be practiced. 46. B. 28. D. As low as reasonably achievable is a concept used 47. D. in radiography to protect both the patient and the 48. C. Air kerma is the x-ray energy being deposited in a radiographer. specific location. 29. A. Epithelial tissue and reproductive cells, including 49. B, F. immature sperm cells, are highly radiosensitive. On 50. D. Coulombs per kilogram is used less frequently. the other hand, adult nerve tissue requires very high 51. B. doses to cause damage, although ALARA must still be 52. B. practiced because once cells are damaged, repair may 53. B. not take place. 54. B. 30. B. In general, these take large doses to manifest them- 55. A. selves. 56. D. 31. D. Repeats double the dose to the patient for each 57. C. exposure. 58. D. 32. C. This is what may cause harmful effects. 59. B. One millisecond 33. D. Ionization is multifaceted. Study tip: Be sure to 60. C. read all choices before choosing an answer. Choice A 61. D. is true, but you must read all the choices to see that 62. D. choice D is the correct answer. 63. A. 34. A. Cell damage may be exhibited as loss of function or 64. C. abnormal function. 65. A. 35. C. Damage from somatic effects is evident in the 66. B. organism being irradiated. Most of the time these 67. A. effects are benign. Genetic damage is passed to the 68. A. next generation. 69. B. 36. A. Somatic effects are evident in the organism being 70. A. irradiated. 71. C. 37. C. There is no control over natural background radia- 72. B. tion, which has been present in the environment since 73. C. the formation of the universe. Choices A, B, and D 74. B. Window width adjusts gray scale. all refer to artificially produced radiation, that made 75. C. by humans. Study tip: Choices A, B, and D are basi- 76. B. Window width adjusts contrast. Window level cally the same; they are too similar for one of them adjusts brightness. to be the correct answer. Choice C is the only unique 77. D. answer. 78. A. 38. C. Natural background radiation, which has been 79. D. present since the formation of the universe, accounts 80. D. for 50% of human exposure. The greatest single 81. D. This is inverse square law. source is radon. 82. D. The image cannot be minified. 39. B. You can safely assume that natural background 83. C. radiation would be below the annual recom- 84. D. mended limits of exposure from diagnostic imaging. 85. B. Daily is best. Although all choices are below this limit, choice B 86. C. is correct. Background exposure is not high but is 87. B. always present. 88. B. 40. C. Radon, which exists as a gas, accounts for 55% of 89. A. human exposure to natural background radiation. 90. A. 41. D. The huge increase in the use of CT since the 1980s 91. C. The total amount of lead in the grid has primarily caused this increase. 92. A. Answers to Review Questions 241

93. B. 135. A. 94. C. 136. B. 95. C. 137. C. 96. B. 138. D. 97. C. It has a short SID. 139. A. Be sure to know all of the major anatomy of the 98. A. It has a long SID. wrist and be able to identify it on radiographs and 99. C. Fewer Compton interactions are occurring. drawings. 100. C. 140. D. 101. C. 141. B. 102. C. 142. C. 103. B. 143. A. Be sure to know all of the major anatomy of the 104. C. shoulder girdle and be able to identify it on radio- 105. D. graphs and drawings. 106. A. Be sure to know all of the major anatomy of the 144. D. urinary system and be able to identify it on radio- 145. B. graphs and drawings. 146. A. 107. B. 147. B. 108. C. 148. C. 109. A. 149. D. Be sure to know all of the major anatomy of the 110. D. Be sure to know all of the major anatomy of the foot and be able to identify it on radiographs and colon and be able to identify it on radiographs and drawings. drawings. 150. D. 111. D. 151. C. 112. C. 152. A. 113. A. 153. B. Be sure to know all of the major anatomy of the 114. B. Be sure to know all of the major anatomy of the elbow and be able to identify it on radiographs and stomach and be able to identify it on radiographs and drawings. drawings. 154. B. 115. B. 155. C. 116. D. 156. D. 117. A. 157. A. Be sure to know all of the major anatomy of the skull 118. C. Be sure to know all of the major anatomy of the and be able to identify it on radiographs and drawings. lumbar spine and be able to identify it on radiographs 158. D. and drawings. 159. C. 119. A. 160. B. 120. C. Be sure to know all of the major anatomy of the 161. A. Be sure to know all of the major anatomy of the cervical spine and be able to identify it on radiographs facial bones and be able to identify it on radiographs and drawings. and drawings. 121. D. 162. A. 122. C. 163. C. 123. B. Be sure to know all of the major anatomy of the hip 164. D. and be able to identify it on radiographs and drawings. 165. C. 124. B. 166. D. 125. C. 167. B. 126. D. 168. B. 127. A. Be sure to know all of the major anatomy of the 169. D. knee and be able to identify it on radiographs and 170. C. drawings. 171. C. 128. B. 172. D. 129. D. 173. B. Infectious waste containers are usually made of 130. A. plastic, but not always. The best answer contains the 131. C. Be sure to know all of the major anatomy of the detail most relevant to the radiographer: You should hand and be able to identify it on radiographs and place infectious waste in containers or bags prop- drawings. erly labeled as to the type of waste therein. Study 132. D. tip: Look out for words like “always” and “never.” 133. B. Choices containing these words are usually not the 134. C. best answer. 242 Answers to Review Questions

174. C. Sharps should never be recapped. 186. C. Because residual barium could compromise any 175. A. Assault, battery, false imprisonment, and invasion exams that follow barium studies, barium studies of privacy are all types of intentional misconduct, but should be scheduled last. assault can be defined as anything the radiographer 187. C. The Centers for Disease Control and Prevention does that causes fear in a patient. Assault can be ver- has specific guidelines that must be followed. bal as well as physical. A remark that causes a patient 188. A. No special equipment is needed to measure respira- to feel apprehensive about being injured is considered tions. assault. 189. D. The wordnasal in the answer helps lead you to the 176. D. Assault, battery, false imprisonment, and invasion correct response. of privacy are all types of intentional misconduct. 190. D. These are items commonly encountered through- Invasion of privacy is a violation of confidentiality of out the day. Contact transmission is person to person. any patient information. Airborne transmission involves such things as droplets 177. D. Negligence, the neglect or omission of reasonable and dust. Droplet transmission is a result of coughs care, is a kind of unintentional misconduct. This kind and sneezes. of misconduct is considered unintentional because it 191. C. The activity of the heart is electrical; therefore arises from an indirect action (not providing care), stimulating the heart with current commonly jolts it rather than an overt action (doing harm). Gross neg- back into proper rhythm. ligence is the kind that demonstrates reckless disre- 192. D. gard for life or limb. Respondeat superior is the legal 193. D. Health Insurance Portability and Accountability Act doctrine that states that an employer is liable for an (HIPAA). CDC stands for Centers for Disease Control employee’s negligent act. Res ipsa loquitur is the legal and Prevention. HHS stands for the Department of doctrine that states that the cause of negligence is Health and Human Services. ALARA stands for as low obvious. as reasonably achievable. 178. B. Pulse is an important vital sign. To detect the pres- 194. D. Cardio refers to the heart. Hypovolemic shock is a ence of bradycardia, the pulse must be taken accu- result of loss of great amounts of blood. Septic shock rately. Tachycardia is defined as more than 100 beats occurs when toxins produced during an infection per minute. Study tip: When two choices are similar cause a dramatic drop in blood pressure. Neurogenic (e.g., “More than 100 beats per minute” and “Fewer shock causes blood to pool in the peripheral vessels. than 60 beats per minute”), one of them is often the 195. B. correct answer. 196. B. 179. A. All the choices except choice A are pieces of equip- 197. A. ment, so they would not contain all equipment and 198. B. drugs needed for respiratory or cardiac arrest. Be sure 199. B. to know the location of the crash cart and its contents. 200. A. Study tip: Be sure to read the questions carefully. Common sense can sometimes help you eliminate Chapter 6 – Challenge Tests – incorrect choices. Test #2 180. D. A sphygmomanometer is also called a blood pressure cuff. Answers to Challenge Test Number 2 181. Aqueous iodine compound may be used if surgery 1. C. More energy is deposited by particulate forms of is imminent, for example, in the case of perforated radiation than by waveforms of radiation. ulcers or a ruptured appendix, where barium could be 2. D. All are examples of radiation effects on the indi- a surgical contaminant. vidual being exposed. 182. C. Most symptoms of contrast media reactions are 3. D. Choice A is incorrect because photoelectric inter- observable, so patients must be carefully watched action produces contrast. when contrast agents are used. 4. C. 183. A. The difference between medical and surgical asep- 5. A. Choice B is incorrect because no level of radiation sis is that surgical asepsis removes all microorganisms. is considered completely safe. Choice C is incorrect Study tip: When two choices are similar (e.g., “Medi- because no such immunity has been proved. Choice cal asepsis” and “Surgical asepsis”), one of them is D is incorrect because the effective dose limit for the often the correct answer. general public is 5 mSv per year. 184. A. Always take a history of the patient! MI stands 6. B. High-LET radiation is depositing a lot of energy in for myocardial infarction. Bx and hs are not medical the tissues, causing much ionization. abbreviations. 7. C. It is assumed that for every dose of radiation, a 185. D. MI stands for myocardial infarction. Hx stands for response occurs in the atoms of the person being irra- history, and CVA stands for cerebrovascular accident. diated. HA is not a medical abbreviation. 8. B. Cells such as epithelial, ovarian, and sperm cells Answers to Review Questions 243

9. D. Because the cellular cytoplasm is substantially not quantity. Film badges do not measure the source larger than the cellular nucleus, it is more likely to be or type of x-ray beam. struck by incoming x-ray photons. Thus most of the 27. D. A film badge should not be worn longer than 1 cellular response to radiation is indirect. The direct month, at which time a film badge report with read- effect results from x-ray photons directly striking the ings is returned to the institution. cellular nucleus. 28. B. Lithium fluoride crystals, which release energy as 10. A. Indirect effect occurs when radiation strikes the visible light when heated, are used to record dose in cytoplasm of the cell. Target theory states there is a TLDs. master molecule that governs cellular activities, that 29. B. TLDs are heated and release visible light energy to is, DNA. indicate dose. This energy is read by a photomultiplier 11. B. tube. 12. D. Be sure to review the units of radiation measure- 30. B. OSL dosimeters are very sensitive. This feature, ment. along with their wide dynamic range, greater accu- 13. B. This is human-produced radiation. racy, and long-term stability, makes them ideal for 14. A. personnel monitoring. 15. A. 31. C. The recording material in an OSL dosimeter is alu- 16. C. Be sure to get the amount and unit of measure- minum oxide, which is then scanned by a laser beam. ment correct! Film badges use film as the recording material; TLDs 17. D. This is the definition of mean marrow dose use lithium fluoride. (MMD). It is not called the bone dose. The doubling 32. C. The energy stored in an OSL dosimeter is released dose is the amount of radiation that causes the num- by exposure to a laser. The energy is then released as ber of mutations in a population to double. The GSD visible light. The energy stored in a TLD is released by is the genetically significant dose. heat. 18. A. This describes the GSD, or genetically significant 33. C. OSL dosimeters can be worn for up to a quar- dose (not called genetic dose). The doubling dose is ter, although in many cases they may be changed the amount of radiation that causes the number of monthly. mutations in a population to double. Mean marrow 34. D. One of the key advantages of OSL dosimeters dose is the average dose to active bone marrow as an is the capability of reanalysis for confirmation of indicator of somatic effects on population. dose, which is especially important if a dose is in 19. B. Shielding of lead (Pb) equivalent, not aluminum question. (Al) equivalent, is used to protect from scatter radia- 35. C. The flat contact shield, which consists of a piece tion. The requirement for a lead apron is at least of lead placed over the gonads, is most commonly 0.25-mm Pb equivalent; it should be 0.5-mm Pb used. It may be as simple as a lead apron properly equivalent, which is what the question asks. There is a placed. The shadow shield, which is suspended from difference between “shall” and “should.” the x-ray housing and does not come in contact with 20. B. The requirement for a thyroid shield, if used, the patient, is used when sterile technique is required. during fluoroscopy is 0.5-mm lead, not aluminum, A collimator is not considered a gonadal shielding equivalent. device. 1 21. D. Primary protective barriers consist of ⁄16-inch 36. D. Low mAs reduce the amount of radiation striking lead equivalent, not aluminum equivalent. Sec- the patient. Choosing the optimum kVp for the part 1 ondary protective barriers consist of ⁄32-inch lead being radiographed increases the quality of the x-ray equivalent. beam. Low kVp, high mAs would result in the oppo- 22. C. Primary protective barriers in the wall must extend site. to a height of at least 7 feet because this height is taller 37. D. The fastest practical speed for the part being radio- than most people. graphed should be used to reduce patient dose. Slow 23. C. The secondary protective barrier extends from speed increases patient dose. where the primary protective barrier ends to the ceil- 38. A. Be sure to review the source-to-skin distance require- ing with a ½-inch overlap. ments. 24. D. The protective curtain hanging from the fluoros- 39. D. Added filtration is adjusted by a medical radiation copy tower must be at least 0.25-mm Pb, not Al, physicist, not by the radiographer. Compensating fil- equivalent. Be sure to remember all the shielding tration devices, such as wedge filters, are manipulated requirements. by the radiographer. 25. D. Be sure to remember all the shielding require- 40. B. ments. 41. C. Radiation effects manifested in the next generation 26. C. Filters made of aluminum and copper are placed are called genetic effects. in the film badge to measure the x-ray energy striking 42. C. Radon is present in the environment as a gas, fre- the film badge. This is a measure of the beam’s quality, quently found in the basements of older homes. 244 Answers to Review Questions

43. C. As a result of differential absorption of the beam, 94. A. This is a directly proportional relationship. photoelectric effect produces contrast on the image. 95. B. This is the inverse square law. 44. C. Air kerma has replaced coulombs per kilogram. 96. A. 45. B. WR is used to modify the absorbed dose amount 97. B. to account for greater damage caused by high-LET 98. B. The beam is more penetrating. radiations. X-rays have lower LET so the WR is only 99. A. Scatter is absorbed by the grid. 1. 100. A. 46. A. 101. B. 47. A. 102. B. This results in magnification of the image. 48. B. 103. A. 49. D. The cytoplasm is larger than the nucleus. 104. D. 50. B. 105. C. 51. B. 106. A. Be sure to review the placement of the carpal bones. 52. B. 107. D. Two similar answers, such as A and D, usually 53. A. indicate that one of them is the correct answer. 54. D. 108. D. The Jefferson fracture is a comminuted fracture of 55. D. Answer B is incorrect because of “silicone,” which the ring of the atlas. is not the same substance used in rectifiers. 109. C. A boxer’s fracture is a transverse fracture of the 56. C. neck of the fifth metacarpal. 57. D. 110. B. A Colles’ fracture is a transverse fracture through 58. B. the distal radius. 59. B. 111. A. Talipes is another term for clubfoot. 60. D. 112. D. Ankylosing spondylitis is an inflammatory disease 61. A. of the spine that causes fusion of the joints involved. 62. C. 113. D. 63. D. 114. D. 64. C. 115. A. 65. A. 116. B. 66. B. 2% of the SID 117. C. 67. B. Some sources indicate it must be within 4-6 kVp. 118. C. Be sure to know all of the major anatomy of the 68. D. hand and wrist and be able to identify it on radio- 69. B. graphs and drawings. 70. D. Highest mAs and highest kVp 119. B. 71. B. Lowest mAs and lowest kVp 120. A. 72. C. 121. D. 73. A. 122. B. 74. A. 123. A. Be sure to know all of the major anatomy of the 75. C. The 15% rule elbow and be able to identify it on radiographs and 76. A. drawings. 77. A. 124. D. 78. B. 125. A. 79. C. 126. B. 80. A. 127. B. 81. A. 128. D. Be sure to know all of the major anatomy of the 82. B. It’s important to choose the correct algorithm for vertebrae and be able to identify it on radiographs and each exam. drawings. 83. C. 129. C. 84. B. 130. B. 85. A. 131. D. 86. D. Picture Archiving and Communication System 132. C. Be sure to know all of the major anatomy of the 87. A. lower leg and be able to identify it on radiographs and 88. C. drawings. 89. B. 133. D. 90. D. 134. B. 91. B. 135. A. 92. B. 136. C. 93. A. The line-focus principle in action 137. A. Answers to Review Questions 245

138. D. Be sure to know all of the major anatomy of the 170. A. shoulder girdle and be able to identify it on radio- 171. C. graphs and drawings. 172. B. 139. D. Choice A is incorrect because this is a radiograph 173. D. of a lower leg. Choice B is incorrect because the tibia 174. C. Breaths not beats and fibula cannot be superimposed. Choice C is 175. D. The key word is must, although radiographers incorrect because both joints should be included. should also be proficient in taking blood pressure. 140. C. Although it is seldom performed, this T-tube chol- As radiographers’ scope of practice expands, so will angiogram shows the hepatobiliary ductwork. the need to be proficient in the use of a wide range 141. B. Be sure to review the anatomy visualized on the of medical instruments. Be aware that in some states elbow obliques. oxygen is considered a medication. 142. C. This is the only choice that places the skull in a true 176. C. Be familiar with all tubes you may encounter in lateral. patient care. 143. A. Note the placement of the petrous ridge. 177. D. These are also called “health care acquired.” 144. B. 178. B. Retrograde flow of urine commonly causes bladder 145. C. infections. The urinary system is the primary site of 146. B. nosocomial infections. 147. D. 179. A. Be sure to wash hands before beginning the exam. 148. C. Be sure to know all of the major anatomy of the 180. B. This question asks which item is not required for “Scotty dog” and be able to identify it on radiographs valid consent. A consent form is not always used. and drawings. 181. B. 149. C. Breathing technique, also known as autotomog- 182. B. raphy, involves placing superimposing structures in 183. A. Always observe standard precautions with every motion while the x-ray tube and IR remain stationary. patient. 150. B. Knowing the effect of injuries helps with position- 184. A. Handwashing is the number one method for pre- ing of the patient and prevents further injury. venting the spread of infection. 151. D. This is a PA axial projection of the clavicle, so the 185. B. This protects the patient and the radiographer from tube angulation is caudad. The tube angulation is injury. cephalad for the AP axial projection. 186. C. Be sure to know what other departments consult 152. C. Note the use of a range in the answer. This is what for relevant information. you will probably encounter on the ARRT exam. 187. D. This is a better answer than A, especially because 153. D. alcohol is not always used. 154. B. Place the proximal femur (the thicker part of the 188. A. Be sure to review the facts about sterile technique. thigh) under the cathode portion of the x-ray beam. A 189. D. Portable machines go everywhere. Be certain that trough filter is used for chest radiography. they are cleaned according to protocol. 155. A. Know those exact centering points. 190. B. This protects both the patient and the equipment 156. D. If this were a PA oblique projection, choice B from contamination. would be correct. 191. D. Patient care is an integral part of the radiographer’s 157. B. This is an AP oblique. responsibility. 158. B. This is a PA oblique. 192. C. Choice 2 is incorrect because this is beyond the 159. C. The second inspiration would be deeper than just radiographer’s scope of practice. Choice 4 is incorrect a single inspiration. This is a more complete and because in a trauma situation, other health care work- descriptive answer than choice A. ers need to be in the room and should be provided 160. A. Be sure you know why certain projections are used. with lead protection. 161. B. Choice 3 is incorrect because the central ray exits at 193. D. This helps reduce cramping. the nasion when the frontal bone is being examined. 194. D. Some are nonionic, which rules out A and B. Choice 4 is incorrect because the MSP is perpendicu- Contrast agents are not pure iodine, which rules out lar to the cassette. choice C. 162. A. 195. B. Be aware of the possible complications when using 163. D. these agents. Know all the details of these pharma- 164. A. ceuticals. 165. D. 196. A. Although it does not occur often, recent exams 166. B. involving iodinated contrast media should be brought 167. D. to the radiologist’s attention. 168. B. 197. C. You can never assume there will be no reactions. 169. B. Choice B is incorrect because other contrasts could 246 Answers to Review Questions

include barium studies, which would not have a risk proportional to the square of the distance from the of reaction. source of radiation. Choice C is incorrect because 198. D. the reciprocity law states that mAs = mAs. Choice D 199. D. Barium is a surgical contaminant. is incorrect because Ohm’s law states that voltage is 200. D. As a professional, you need to know the continu- equal to current times resistance in a circuit. ing education requirements of your chosen field. Be 19. A. Indirect effect occurs when radiation strikes the sure to know your state’s statutory requirements as cytoplasm. This causes the formation of free radi- well. Consult http://www.arrt.org. cals and hydrogen peroxide, which damage the cell. Choice B is incorrect because the law of Bergonié Chapter 6 – Challenge Tests – and Tribondeau describes the radiosensitivity of cells. Test #3 Choice C is incorrect because target theory explains that DNA is the master molecule of the cell. Choice Answers to Challenge Test Number 3 D is incorrect because indirect effect causes about 1. D. Remnant radiation exits the body (choice A); 95% of the cellular response. gamma radiation is not produced in the x-ray tube 20. D. Direct effect occurs when radiation directly hits (choice B). Choice C, nonionizing radiation, is incor- the cellular nucleus. Indirect effect occurs when radia- rect because x-rays are ionizing radiation. tion strikes the cytoplasm of the cell. 2. C. Choice A is incorrect because Compton produces 21. B. scatter radiation. Choice B is incorrect because coher- 22. B. ent scatter is produced at extremely low kVp levels. 23. B. Choice D is incorrect because pair production occurs 24. A. only at levels above 1.02 MeV. 25. D. Choice A is incorrect because this term is no lon- 3. A. Choice B is incorrect because coherent scatter ger used. Choice B is incorrect because ALARA stands occurs at extremely low kVp levels and does not pro- for as low as reasonably achievable. duce a recoil electron. Choice C is incorrect because 26. C. the photoelectric effect does not scatter the photon. 27. B. The exposure switch on a portable x-ray machine Choice D is incorrect because pair production does must be attached to a cord that is at least 6 feet long. not occur in diagnostic radiography. This does NOT mean six feet is a safe distance. A lead 4. A. apron must still be worn when performing mobile 5. B. radiography. 6. A. 28. B. Under no circumstances should the radiographer 7. A. be exposed to the primary beam. 8. A. 29. D. For proper radiation protection, x-ray tubes oper- 9. D. The t refers to tissue. ating above 70 kVp must have total filtration of at 10. C. Linear energy transfer least 2.5-mm aluminum equivalent. Lead is not used 11. A. as a filter material. 12. D. Choice A is incorrect because contrast is produced 30. B. Choice A is incorrect because gonadal shielding by photoelectric effect, not Compton interaction. may obstruct the area of interest in some projections. 13. B. Choice C is incorrect because male patients must also 14. B. Genetic effects may express themselves in future be shielded. Choice D is incorrect because the gonads generations as mutations. must be protected outside of pregnancy as well. 15. D. Be sure to know all the dose limits. 31. D. The secondary protective barrier must overlap the 16. B. National Council on Radiation Protection and primary protective barrier by at least ½ inch to pre- Measurements. Choice A, the International Commis- vent leakage after the building has settled. sion on Radiological Protection, is incorrect. Choice 32. A. The primary beam is never aimed at the control C is incorrect, but the Nuclear Regulatory Com- booth. The exposure switch in the x-ray control booth mission does have enforcement power. Choice D is must have a cord short enough that the radiographer incorrect because the American Society of Radiologic has to be behind the secondary protective barrier to Technologists is the professional organization for radi- operate the switch. ation science professionals. 33. B. The exposure switch in the x-ray control booth 17. C. Choices A and D are incorrect because there is no must have a cord short enough that to operate the threshold dose regarding radiation protection. Choice switch, the radiographer must be in the control booth, B is incorrect because we do not assume a nonlinear not simply behind the x-ray tube. The control booth response for radiation protection. is a secondary, not a primary, protective barrier. 18. B. Choice A is incorrect because the inverse square 34. B. Waiting rooms and stairways are considered uncon- law states that the intensity of radiation is inversely trolled areas. They are shielded to keep exposure under Answers to Review Questions 247

0.5 rem annually. Controlled areas are those occupied 57. D. by persons who are trained in radiation safety and are 58. D. wearing personnel monitoring devices. There is no 59. C. This is to repel the electrons. specific area known as the off-limits area or the radia- 60. D. tion area. 61. C. 35. D. 62. D. 36. A. Controlled areas are those occupied by persons 63. A. who are trained in radiation safety and are wearing 64. C. personnel monitoring devices. Uncontrolled areas 65. A. 2% of the SID are general public areas, such as stairways and wait- 66. C. ing rooms. There is no specific area known as the off- 67. A. limits area or the radiation area. 68. B. 37. D. Workload, measured in mA minutes per week, 69. C. takes into account the volume and types of exams 70. C. performed in the room. The use factor is the amount 71. C. of time the beam is on and directed at a particular bar- 72. C. rier. There is no specific shielding factor. 73. B. Be familiar with the various modes of postprocessing. 38. C. Workload, measured in mA minutes per week, 74. A. takes into account the volume and types of exams 75. A. Patient dose may be lower. performed in the room. Half-value layer is the thick- 76. C. ness of absorbing material required to reduce the x-ray 77. A. Digital communication in medicine beam to half its original intensity. The amount of time 78. A. Too few photons creating the image the beam is on and directed at a particular barrier is 79. B. called the use factor. 80. B. 39. A. The amount of time the beam is on and directed 81. C. at a particular barrier is called the use factor. Work- 82. B. load, measured in mA minutes per week, takes into 83. D. H/D account the volume and types of exams performed 84. D. in the room. Occupancy is a determinant of barrier 85. A. thickness that simply takes into account who occupies 86. D. 2% of the SID a given area. There is no specific shielding factor. Be 87. D. Be sure to read all choices carefully. sure to review the determinants of barrier thickness 88. C. factors. 89. B. The average wavelength of the beam decreases. 40. C. It is measured at a distance of 1 meter because that 90. D. is where the patient would be. 91. D. 41. B. The cytoplasm contains water and the organelles, 92. D. each of which plays a role in the functioning of the 93. D. cell. 94. B. 42. A. RBE varies with the type of radiation and its LET. 95. B. 43. B. A is the inverse square law; C is Ohm’ law. 96. D. 44. C. Muscle cells are the least radiosensitive cells in the 97. A. body. 98. D. 45. A. However, following ALARA at all times is of para- 99. C. mount importance. Embryologic effects are most 100. D. likely to occur during the first trimester. 101. B. This is a direct relationship. 46. A. This should be the only source of occupational 102. C. Less Compton scatter produced exposure. 103. D. Be sure to review the Bucky factors. 47. A. 104. D. 48. D. The requirement is no less than 12 inches. 105. C. 49. B. 106. B. 50. B. 107. A. 51. C. 108. B. Be sure to review these definitions. You are not 52. B. The filter is made of aluminum. likely to be asked more than one on the Registry 53. B. exam, but you will want to get it correct. 54. D. 109. D. 55. C. 110. C. 56. C. 111. A. 248 Answers to Review Questions

112. D. 151. D. 113. B. Review the various types of joints so you will be 152. A. able to handle any question you are asked about them. 153. D. 114. D. 154. C. 115. D. 155. B. 116. A. 156. C. 117. D. 157. D. 118. C. Be sure to review the major anatomy of the skull. 158. D. Even though routine skull series are seldom per- 159. D. formed, having been replaced by computed tomogra- 160. B. phy, skull questions are still asked on the ARRT exam. 161. C. 119. A. 162. A. 120. B. 163. C. 121. D. 164. B. 122. B. 165. D. 123. C. 166. A. 124. B. 167. A. 125. D. The preceding series of positioning questions has illustrated 126. D. the level of knowledge you need going into the Registry exam. 127. D. Be sure to review carefully and accurately. Do not panic. Just 128. D. review some every day until you have mastered these facts. 129. C. 168. B. 130. D. 169. A. 131. D. It is important to be able to “label” anatomy 170. B. whether on drawings, on radiographs, or, as these 171. B. questions illustrate, by using words. 172. B. 132. C. 173. B. 133. A. 174. A. 134. B. 175. D. Torts are a part of personal injury law. 135. D. 176. C. Invasion of privacy involves violating confidential- 136. D. ity or improperly exposing the patient’s body to view- 137. B. ing or radiation. Assault and battery involve threats 138. C. and striking the patient. 139. A. 177. B. 140. A. 178. C. 141. D. Be comfortable with answering questions regard- 179. B. Respondeat superior means “let the master answer.” ing the alimentary canal and the urinary system. These Gross negligence is a reckless disregard for life or limb. types of questions are asked on the certification exam. Slander is spoken defamation. Study tips: For the following series of questions, be sure to 180. A. The heartbeat is regular but rapid. know the exact centering point that you learned in position- 181. C. Diastolic pressure is the blood pressure of the heart ing class and from Chapter 5 of this text. Also be aware that at rest. in some Registry exam questions you may be given ranges of 182. D. Be sure to know the correct amount per unit time. angles from which to choose, making it easier to choose the Choice A would be damaging. The other choices correct answer. This may occur because not all positioning would be inadequate. Read carefully. textbooks agree on certain angles. 183. B. The crash cart contains everything needed for 142. D. a code blue, a defibrillator restores errant heart- 143. D. beat, and the sphygmomanometer measures blood 144. B. This is difficult for a patient with an elbow injury. pressure. 145. A. Distinguish between PA and AP. Be sure to read the 184. C. The crash cart contains everything needed for a question carefully. Remember that the humerus and code blue, a defibrillator restores errant heartbeat, and forearm must also be in the same plane. the sphygmomanometer measures blood pressure. 146. D. 185. D. Choice A is incorrect because hypovolemic shock 147. D. is caused by a loss of fluids. Choice B is incorrect 148. D. because septic shock follows massive infection. Choice 149. B. C is incorrect because neurogenic shock causes blood 150. A. to pool in peripheral vessels. Answers to Review Questions 249

186. B. Gastric indicates that it flows into the stomach. 193. D. This can be caused by the mere suggestion of a Knowledge of medical terminology will greatly assist in reaction. ruling out some answers and carefully considering others. 194. D. Literally, inflammation of a vein 187. D. You do not want urine to flow backward into the 195. D. Contact is person to person, airborne is droplets bladder, causing an infection. and dust, and droplet is coughs and sneezes. 188. A. Great care must be taken when performing a por- 196. C. As explained in question 195 table chest x-ray exam on a patient who is receiving 197. A. As explained in question 195. Be sure to keep all of mechanical ventilation. these facts straight. 189. D. Be sure to observe the F or C. You would not want 198. B. Medical asepsis is not the complete removal, and to mix barium in water at 100° C. gas sterilization is a way to sterilize equipment, not a 190. A. Choice C does not make sense. Air is a gas, and patient care environment. iodine is not inert. 199. A. 191. D. 200. D. Be sure to review the major medical terms you 192. A. learned early in your program.

Bibliography

https://www.arrt.org/ Long B, Rollins J, Smith B: Merrill’s atlas of radiographic positioning Bontrager K, Lampignano J: Textbook of radiographic positioning and and procedures, ed 13, St. Louis, 2016, Elsevier. related anatomy, ed 8, St. Louis, 2013, Elsevier. Mace J, Kowalczyk N: Radiographic pathology for technologists, ed 5, Bushong S: Radiologic science for technologists, ed 10, St. Louis, 2012, St. Louis, 2009, Elsevier. Elsevier. National Council on Radiation Protection and Measurements: Limi- Callaway WJ: Graduate technologists and customer service, Radiol tation of exposure to ionizing radiation, NCRP Report No. 116, Manage 14:50, 1992. Bethesda, 1993, NCRP. Carter C, Vealé B: Digital radiography and PACS, ed 2, St. Louis, National Council on Radiation Protection and Measurements: Medical 2013, Mosby. x-ray, electron beam and gamma-ray protection for energies up to MeV Ehrlich R, Coakes D: Patient care in radiography: with an introduction (equipment design, performance and use), NCRP Report No. 102, to medical imaging, ed 8, St. Louis, 2013, Elsevier. Bethesda, 1989, NCRP. Eisenberg R, Johnson N: Comprehensive radiographic pathology, ed 5, National Council on Radiation Protection and Measurements: St. Louis, 2012, Elsevier. Quality assurance for diagnostic imaging, NCRP Report No. 99, Fauber T: Radiographic imaging and exposure, ed 4, St. Louis, 2013, Bethesda, 1988, NCRP. Elsevier. National Council on Radiation Protection and Measurements: Ioniz- Gurley L, Callaway WJ: Introduction to radiologic technology, ed 7, ing radiation exposure of the population of the United States, NCRP St. Louis, 2011, Elsevier. Report No. 160, Bethesda, 2006, NCRP. Jensen S, Peppers M: Pharmacology and drug administration for imag- Papp J: Quality management in the imaging sciences, ed 5, St. Louis, ing technologists, ed 2, St. Louis, 2006, Mosby. 2015, Elsevier. Johnston J, Fauber T: Essentials of radiographic physics and imaging, Sherer M, Visconti P, Ritenour E, Haynes K: Radiation protection in ed 2, St. Louis, 2015, Elsevier. medical radiography, ed 7, St. Louis, 2014, Elsevier.

250

Illustration Credits

Figures 3-1, 3-2, 4-2, 4-3, 4-4, 4-7 through 4-16—From Figure 2-1—From Cummings, et al.: Perspectives in athletic Fauber TL: Radiographic imaging & exposure, ed 4, St. Louis, training, ed 1, St. Louis, 2009, Mosby. 2012, Mosby. Figure 2-2—From Freedman: Contemporary esthetic den- Figure 4-1—From Buschong SC: Radiologic science for tech- tistry, ed 1, St. Louis, 2012, Mosby. nologists: physics, biology and protection, ed 10, St. Louis, Figures 6-1 through 6-14—From Bontrager KL: Textbook 2012, Mosby. of radiographic positioning and related anatomy, ed 8, St. Figures 4-5 and 6-15—From Malott JC, Fodor J III: The Louis, 2013, Mosby. art and science of medical radiography, ed 7, St. Louis, 1993, Mosby. Figures 5-19 through 5-62 and 6-17 through 6-26— From Frank E: Merrill’s atlas of radiographic positions and radiologic procedures, ed 12, St. Louis, 2011, Mosby.

251

Index

A Anatomy (Continued) Ascending colon, 114 ABC. see Automatic brightness control (ABC) bones of thorax in, 102–103 Asepsis, 7 Abdomen and contrast, 74 medical, 15, 24 anatomy of, 96 of digestive system, 112–114 surgical, 15, 24–25 radiographic procedures for, 140, 141f digital image receptor exposure and, 73 ASIS, 103 Abdominal aorta, 110 of heart, 109–111 Assault, 15, 17 Abdominal viscera, 114f of lymphatic system, 111 Asthenic body habitus, 94 Abduction, 97 of nervous system, 108–109 Asthma, 130 Absenteeism, administrators and, 224 planes of the body in, 95–96 Atelectasis, 130 Absorbed dose, unit of, 40 of respiratory system, 111–112 Atomic mass, 58 AC. see Alternating current (AC) of skeletal system, 96–108 Atomic number, 58, 74 Academic degrees, 208–209, 209b appendicular skeleton in, 103–108 Atria, 109 Acanthiomeatal line (AML), 91, 93 articulations in, 97 Attenuation, 39, 41, 58 Acceleration, 58 axial skeleton in, 97–103 Auditory area, 108 Accreditation, 203 descriptive terminology for, 96 Auditory tube, 111 Acromegaly, 116 division of, 96–97 Autoclaving, 25 Acromioclavicular articulations, radiographic facial bones in, 99–100 Automatic brightness control (ABC), 48, 66 procedures for, 121 lower extremity in, 103–108 on image intensifier, 68 Acute cholecystitis, 140 marrow in, 96 Automatic brightness stabilization, 66 Acute radiation syndromes, 8 ossification in, 96 Automatic collimation, 47 Added filtration, 47 skull in, 97–99, 98f Automatic exposure control (AEC), 9, 60–61 Addison’s plane, 96 skull morphology in, 97 quality control of, 68 Adduction, 97 types of, 96 Automatic exposure rate control (AERC), 48 Adenoids, 111 upper extremity in, 103 Automatic gain control, 66 Administrators, expectations of, 223–224 vertebral column in, 100–102 Autonomic nervous system (ANS), 108 Adult respiratory distress syndrome, 130 of urinary system, 114–116 Autotransformer, 59–60 Advance directive, 15, 19 Angulation, 116 Avulsion fracture, 116 Advanced degrees, 208, 209b Ankle Axial, 91 AEC. see Automatic exposure control (AEC) anatomy of, 106–108 Axial plane, 96 AERC. see Automatic exposure rate control radiographic procedures for, 123–124, Axial skeleton, 96–97 (AERC) 123f–124f Axillary artery, 110 Air gap technique, 78 Ankylosing spondylitis, 116 Azygos vein, 111 Air kerma, 39–40 Annual dose limits, 42–44, 44b patient protection for, 48 Annual living expenses, 197, 198f B Airborne precautions, 15, 25 Anode, 62 Baccalaureate degrees, 208, 209b Airborne transmission, 15, 24 ANS. see Autonomic nervous system (ANS) Background radiation ALARA. see As low as reasonably achievable Anterior, 91 medical, 41 (ALARA) Anthracosis, 131 natural, 39, 41 Alignment, 92 Anus, 114 Ball and socket joint, 97 Alimentary tract, 112 Aorta, 109 Bandages, 95 Allergic shock, 16, 27 Aortic arch, 109–110 Barium, 29 Alternating current (AC), 59 Aperture diaphragm, 47 Battered child syndrome, 116 Alveolar ducts, 112 Appearance, at interview, 217–218 Battery, 15, 17 Alveolar process, 99 Appendicular skeleton, 97, 103–108 Beam characteristics, 64–65 American Registry of Radiologic Technologists Application process, examination, 11 Beam limitation, and patient exposure, 47 (ARRT), 221 Aqueous iodine compounds, 16, 29 Beam-part-receptor alignment latitude, 71 examination, 154 Arachnoid, 109 Beam restriction Mission and Standards of Ethics, 19, 19b–21b ARRT. see American Registry of Radiologic and contrast, 74 Standard Definitions, 70t Technologists (ARRT) and digital image receptor exposure, 73 AML. see Acanthiomeatal line (AML) Arterial systemic circulation, 109–110 Becquerel, 39 Amphiarthroses, 97 Arteries, 109 Bile ducts, 114 Anaphase, 44 Arterioles, 109 Bimalleolar fracture, 116 Anaphylactic reactions, to contrast agents, 16 Arteriovenous shunt, 109 Biohazardous materials, handling and disposal of, Anaphylaxis, 27 Arthrography, 145–146 31–32, 31f Anastomosis, 109 Articular processes, 100 defined, 16 Anatomic markers, 92 Articulations, 97 Biohazardous waste container, 31f Anatomic nucleus, 58 Artificially produced radiation, 39 Biohazardous waste symbol, 31f Anatomy, 95–116, 116b As low as reasonably achievable (ALARA), 39, Biological effects, of ionizing radiation, 45 of abdomen 43, 47 direct, 45 anatomic divisions of, 96 in pediatric radiography, 95 indirect, 45 clinical divisions of, 96 Asbestosis, 131 Black/white reversal, 71

Note: Pages followed by b, t, or f refer to boxes, tables, or figures, respectively.

252 Index 253

Bladder Cathode assembly, 62 Collimator field to radiation field alignment, 68 anatomy of, 114 Caudal, 91 Colon carcinoma of, 143 CDC Standard Precautions, 7 anatomy of, 114 Blood cells, radiosensitivity of, 45 Cecum, 114 AP projection, barium enema of, 160f Blood pressure, 15, 26–27 CED. see Cumulative effective dose (CED) cancer of, 960 Body habitus, 94, 94b Celiac artery, 110 radiographic procedures for, 142–143, 142f Body part placement, 92 Cell division, 44 Comfort, of patient, 23 Boiling, for surgical asepsis, 24 Cell line death, 45 Comminuted fracture, 116 Bone marrow, 96 Cell membrane, 44 Common iliac arteries bifurcate, 110 Bones, 96 Cells, 44, 46b Common vehicle transmission, 15, 24 Bony cyst, 116 biological effects on, 45 Communication Bowing fracture, 116 division of, 44 interpersonal, 6–7 Boxer’s fracture, 116 genetic effects of radiation on, 46–47 nonverbal, 15–16 Brachiocephalic artery, 109 main parts of, 44 with patient, 16–17 Brachycephalic skull, 97 radiosensitivity of, 45–46 verbal, 15–16 Bradycardia, 15 somatic effects of radiation on, 46 Complete fracture, 116 Brain, anatomy of, 108 Central, 91 Compound fracture, 116 Bremsstrahlung (brems) radiation, 63, 63f Central fissure, 108 Compression fracture, 116 British system, 58 Central nervous system (CNS), 108 Compton effect, 39 Broca’s area, 108 Central nervous system syndrome, 46 Compton interactions, 41–42, 42f Bronchial adenoma, 130 Centrosomes, 44 Compton scattering, 41, 42f Bronchiectasis, 130 Cerebellum, 108 Computed radiography, image characteristics, Bronchioles, 112 Cerebral arterial circle, 110 71–72, 72b Bronchogenic carcinoma, 130 Cerebral cortex, 108 Conductor, 59 Bucky factor, 77 Cerebrum, 108 Condyle, 96 Bucky slot shield, for fluoroscopy, 50 Certification exam, 14b Condyloid joint, 97 Bursae, 97 Cervical spine Congenital hip anomaly, 116 Bursitis, 116 anatomy of, 100–101 Consent injuries in, 95 implied, 15, 18 C oblique, 162f informed, 15 Calcaneus, radiographic procedures for, 123 topography of, 93 Contact precautions, 15, 25 Calendar, for scheduling study time, 3, 4f Cervical vertebrae, radiographic procedures for, Contact transmission Callus, 116 126–127, 126f–128f direct, 15, 24 Capillaries, 109 CGS system, 58 indirect, 15 Capitulum, anatomy of, 103 Challenge tests, 154–194 Continuing education, 203–205 Carcinogenesis, 46 on image production, 157–159, 171–174, key points on, 205b Cardiac arrest, 16, 27 172f, 186–189 meeting professional and governmental Cardiac cycle, 109 on patient care, 166–168, 181–183, requirements for, 203–204 Cardiac notch, 112 192–194 opportunities for, 204–205 Cardinal principles of radiation protection, 40, 49 on procedures, 160–166, 160f–166f, Continuing Qualification Requirements Cardiogenic shock, 16, 27 174–181, 175f–179f, 189–192 (CQR), 205 Cardiovascular reactions, to contrast agents, 16, on safety, 154–157, 168–171, 183–186 Continuous x-ray spectrum, 64 30 scoring of, 168, 168t, 183, 183t, 194, 194t Contrast, 74–75, 74b Career paths, 195–209 Characteristic radiation, 64, 64f Contrast agent(s) academic degrees in, 208–209, 209b Charting, medicolegal aspects of, 18 aqueous iodine compounds as, 16, 29 career planning inventory for, 196–200, 198f, Chemical(s), handling and disposal, 31 iodinated 200b Chemical energy, 58 ionic, 16, 29 continuing education requirements in, Chemical sterilization, 24 nonionic, 29 203–205 Chest, radiographic procedures for, 131–133, patient care preceding injection of, 29 key points on, 205b 132f negative, 16, 29 meeting professional and governmental Chest tube, 16, 28 positive, 16, 29 requirements for, 203–204 Child, radiography in, 94–95, 95b Contrast enhancement, 71 opportunities for, 204–205 Cholelithiasis, 960 Contrast improvement factor, 77 Continuing Qualification Requirements in, 205 Chronic bronchitis, 130 Contrast media, 29–30 goal setting for, 200–203, 203b Chronic obstructive pulmonary disease (COPD), barium as, 29 in radiologic specialties, 205–208 130 complications and reactions to, 30 diagnostic medical sonography as, Circle of Willis, 110 iodinated, 29 205–206 Circulatory system, 109 key review points on, 30b as imaging manager, 208 Circumduction, 97 pharmacology and, 29–30 key points on, 209b Classical scatter, 42 Contrast resolution, 74 nuclear medicine as, 206 Clavicle Contributory negligence, 17 other, 207 anatomy of, 103 Controlled area, 50 radiation therapy technology as, 206–207 radiographic procedures for, 122 COPD. see Chronic obstructive pulmonary as radiography educator, 207–208 Clinical coordinator, 208 disease (COPD) as radiologist assistant, 207 Closed fracture, 116 Coronal plane, 91, 96 Career planning inventory, 196–200, 198f, 200b Clothing, for interview, 217 Coronary sinus, 111 C-arms, 67 Clubfoot, 116 Corpus callosum, 108 Carotid arteries, 110 CNS. see Central nervous system (CNS) Cortex, 114 Carpal bones, 103 Coccygeal vertebrae, anatomy of, 102 Coulombs/kilogram, 40 Cart transfer, 23 Coccyx, radiographic procedures for, 130 Cover letter Cartilaginous joints, 97 Code of Ethics, of American Registry of appearance of, 215–216 Cataractogenesis, 46 Radiologic Technologists, 19b–21b for general mailing, 210, 210f Catheter(s) Coherent scatter, 42 in response to job posting, 215, 215f intravenous (IV), 16 Colles’ fracture, 116 Coworkers, expectations of, 226–227 urinary, 28 Collimation, automatic, 47 CQR. see Continuing Qualification Requirements venous, 28 Collimator, 47 (CQR) 254 Index

Cranial, 91 DNR. see Do not resuscitate order (DNR) EMF. see Electromotive force (EMF) Cranial nerves, 109 Do not resuscitate order (DNR), 15, 18 Emphysema, 131 Cranium Dolichocephalic skull, 97 Employment expectations, 221–227 anatomy of, 97 Dorsal decubitus, 91 of administrators, 223–224 radiographic procedures for, 134, 134f–136f Dorsal recumbent, 91 on entering health care workforce, 221 Crash cart, 16 Dose, 49 key points on, 226b Credentials, on resume, 212f–214f, 215 cumulative effective, 39, 44 of new coworkers, 226–227 Crest, 96 doubling, 46 organizational structure and professional Cribriform plate, 99 equivalent, 39 responsibility in, 223–227 Crohn’s disease, 140 genetically significant, 39, 48 of physicians, 224 Crossed grids, 77, 77f mean marrow, 40, 48 of radiology manager, 224–225 Crosshatch grids, 77 Dose area product (DAP), 48 of students under supervision, 225–226 Croup, 130 Dose limits task inventory for, 221–223 Cuboid bone, 108 annual, 42–44, 44b Employment experiences, on resume, 211, Cumulative effective dose (CED), 39, 44 effective, 39, 43 212f–214f Cylinder cones, 47 Dose-response curves, 39 Empyema, 131 Cystic artery, 110 Dose-response evaluations, agencies involved EMR. see Electronic medical record (EMR) Cystic fibrosis, 131 in, 42 Endocardium, 109 Cystitis, 143 Dose-response relationships, 43 Endocrine gland, 114 Cystography, 144–145 linear-nonthreshold, 43, 43f Endoplasmic reticulum, 44 Cystourethrography, 144–145 linear-threshold, 43, 43f Endoscopic retrograde cholangiopancreatography Cytoplasm, 44 nonlinear-nonthreshold, 43, 43f (ERCP), 143 nonlinear-threshold, 43, 43f Energy, 58 D Dosimeters chemical, 58 DAP. see Dose area product (DAP) optically stimulated luminescence conservation of, 58 DC. see Direct current (DC) (OSL), 51 electrical, 58 Decubitus position, 91 thermoluminescent, 51 electromagnetic, 58 Deltoid tuberosity, 103 Doubling dose, 46 kinetic, 58 Deoxyribonucleic acid (DNA), 44 DR. see Digital radiography (DR) nuclear, 58 Depressions, in bone, 96 Droplet precautions, 15, 25 potential, 58 Descending aorta, 110 Droplet transmission, 15, 24 thermal, 58 Descending colon, 114 Dry heat, for surgical asepsis, 25 Entry-level radiographer, 223 Deterministic effects, 39, 43 Duodenum, 113 Epiphysis, 96 Diagnostic medical sonography, 205–206 Dura mater, 108 Epithelial tissue, radiosensitivity of, 45 Diaphysis, 96 Durable power of attorney, 15, 19 Equipment Diarthroses, 97 for digital imaging, 68–70, 70b–71b Diastolic pressure, 15, 26 E computed radiography as, 68–69, 68f DICOM. see Digital imaging and Early somatic effects of radiation, 40, 46 digital radiography for (DR), 69, 69f communications in medicine (DICOM) Edema, tracheolaryngeal, 27 imaging informatics as, 69–70 Digestive system. see Gastrointestinal system Edge enhancement, 71 quality control of, 70 Digital fluoroscopy, 66, 67f Education, on resume, 212f–214f, 215 workstation monitors as, 69 Digital image acquisition, 68–79 Effective dose, 40 for fluoroscopy computed radiography for, 68–69, 68f cumulative, 39, 44 digital, 66, 67f digital radiography for (DR), 69, 69f limit, 39, 43 mobile, 67, 67b imaging informatics as, 69–70 unit of, 40 non-digital, 65 properties of, 72–74 Effective focal-spot size, 68 operation and quality, 9–10 workstation monitors as, 69 Elbow for x-ray production, 60–62, 60f Digital imaging and communications in medicine AP projection of, 165f automatic exposure control (AEC) as, (DICOM), 69 fractures, 116 60–61 Digital imaging characteristics, 9 radiographic procedures for, 119–120, autotransformer as, 60 Digital imaging equipment, 68–70, 70b–71b 120f electronic timer as, 60 quality control of, 70 Electrical circuits, 59 falling load generator, 61 Digital radiography (DR), 69, 69f Electrical current, 59 glass envelope with window as, 62 artifacts in, 71–72 Electrical energy, 58 mA control (filament control) as, 61 image characteristics, 71–72, 72b Electrical generator, 59 mAs timer as, 60 Digits, radiographic procedures for, 117 Electrical motor, 59 milliammeter (mA meter), 61 Direct contact precautions, 15, 24 Electrical resistance, 59 prereading voltmeter as, 60 Direct current (DC), 59 Electrification, 59 quality control of, 67–68, 68b Direct effect, 39, 45 methods of, 59 rectifier as, 61 Direct question, 13 Electrocardiogram, 109 step-up transformer as, 61 Direction, as markers, 92 Electrodynamics, 59 timer as, 60–61 Discrete x-ray spectrum, 64 Electromagnet, 59 tube housing as, 62 Disk herniation, 116 Electromagnetic energy, 58 x-ray tube as, 62, 62f Dislocation, 116 Electromagnetic induction, 59 Equivalent dose, 39 Displacement, 116 Electromagnetism, 59 unit of, 40 Distal, 91 Electromotive force (EMF), 59 ERCP. see Endoscopic retrograde Distance Electron, recoil, 42 cholangiopancreatography (ERCP) barrier thickness and, 50 Electron shells, 58 Errors, technical, artifacts related to, 72 digital image receptor exposure and, 73 Electron-binding energy, 58 Esophageal varices, 960 radiation exposure and, 40, 49 Electronic medical record (EMR), 70 Esophagitis, 140 Distortion, 76, 76b Electronic timer, 60 Esophagus, 113 factors controlling, 76 Electrostatics, 59 cancer of, 140 Distracters, 13 law of, 59 radiographic procedures for, 140–141 Diversity, 15–16 Elongation, 76 Ethmoid bone, anatomy of, 99 Diverticulitis, 140 Embryologic effects, 46 Eustachian tube, 111 DNA. see Deoxyribonucleic acid (DNA) Emergencies, medical, 27–28 Ewing’s sarcoma, 116 Index 255

Examination Fluoroscopy (Continued) Grid errors, 78 certification, 14b mobile, 67, 67b Grid frequency, 77 content categories in non-digital, 65 Grid motion, 77–78 analysis of, 6 exposure rate, 68 Grid radius, 77 biological aspects of radiation, 8 patient protection for, 48 Grid ratio, 76 equipment operation and quality control Flux gain, 66 Grids, 76–79, 76f, 78b as, 9–10 Focal spot, 62 characteristics, 77 image acquisition and evaluation as, 9, 9t Focal spot size construction of, 76–77 radiation protection as, 8–9 effective, 68 and contrast, 74 materials needed for, 12–13 and spatial resolution, 75, 75f crossed, 77, 77f physically and mentally preparing for, 12 Focused grids, 77, 77f focused, 77, 77f procedure for, 10–11 Foley catheter, 28 linear, 77 extremity, 11 Follow-up letter, 220, 220f moving, 77 head, spine, and pelvis, 10 Fontanelles, 97 patient exposure with, 48 thorax and abdomen, 11 Foot and radiographic quality, 78 results of, 14 anatomy of, 106–108, 107f selectivity of, 77 specifications for, 6, 6t oblique, 164f stationary, 77–78 strategies for taking, 13–14, 13b radiographic procedures for, 122–123, 123f use of, 76 Exhibit question, 13–14 Foramen, 96 Groove, 96 Exit radiation, 39, 41 Foramen lacerum, 99 Gross negligence, 17 Exocrine gland, 114 Foramen magnum, anatomy of, 99 GSD. see Genetically significant dose (GSD) Expectations Foramen ovale, 99 Guessing, at answers, 14 of administrators, 223–224 Foramen rotundum, 99 of new coworkers, 226–227 Foramen spinosum, 99 H of physicians, 224 Forearm, 103, 105f H2O2. see Hydrogen peroxide (H2O2) of radiology manager, 224–225 radiographic procedures for, 119, 119f–120f Half-value layer, 47, 65 of students under supervision, 225–226 Foreshortening, 76 Hand Expiration, 112 Fossa, 96 anatomy of, 103, 105f as marker, 93 Fracture healing, 116 PA radiograph of, 163f Exposure factors, 47–48 Fractures, 116–117. see also specific types radiographic procedures for, 118 Exposure linearity, 68 Free radicals, 45 Handheld ionization chamber, 51 Exposure maintenance formula, 73 Frequency, 58 Handwashing, 15 Exposure modification, 94, 94b Frontal bone, anatomy of, 97 Hangman fracture, 117 Exposure reproducibility, 68 Frontal lobe, 108 Hazardous materials, 31–32, 32f Exposure switch, for fluoroscopy, 50 handling and disposal of, 31–32, 31f Extension, 97 G key review points on, 32b External iliac artery, 110 Gallbladder, 114 Head, of bone, 96 External jugular vein, 111 Gamma rays, 58 Health Insurance Portability and Accountability External marker, 93 Gas sterilization, 25 Act (HIPAA), 15, 18 External occipital protuberance, 99 Gastric duodenal artery, 110 Heart, anatomy of, 109–111 Gastritis, 140 Heartbeat, 109 F Gastrointestinal (GI) syndrome, 46 Heat units, 65 Facial bones Gastrointestinal system Heel, anatomy of, 106 anatomy of, 99–100 anatomy of, 112–114 Hematopoietic syndrome, 46 parietoacanthial (Waters) projection of, 166f radiographic procedures for, 140–146 Hepatic artery, 110 radiographic procedures for, 136, 137f GCF. see Grid conversion factor (GCF) Heterogeneous beam, 39, 41, 64 Falling load generator, 61 Geiger-Mueller detector, 51 Hiatal hernia, 140 False imprisonment, 15, 17 Generator High-voltage transformer, 61 Fatty marrow, 96 electrical, 59 Hilus, 112 Femoral artery, 110 falling load, 61 Hinge joint, 97 Femur Genetic effects, 39, 46–47 Hip anatomy of, 106, 106f Genetically significant dose (GSD), 39, 48 anatomy of, 103–105 radiographic procedures for, 125–126 Geometric properties, of radiographic images, inferosuperior projection, 162f Fibrous joints, 97 effect of variables on, 79t radiographic procedures for, 126, 126f Fibula, anatomy of, 106, 106f Giant cell myeloma, 117 HIPAA. see Health Insurance Portability and Filament circuit, 61–62 Glabellomeatal line, 91, 93 Accountability Act (HIPAA) Film badges, 51 Glass envelope with window, 62 HIS. see Hospital information system (HIS) Filtration Gliding joint, 97 Histogram, 71 beam characteristics and, 64–65 Gliding movement, 97 Histoplasmosis, 131 contrast and, 74, 75f Glomerulonephritis, 143 History, patient, 15, 22–23, 23b patient exposure and, 47 Gloving, 25 Hospital information system (HIS), 69 added, 47 Goal setting, in career planning, 200–203, 203b Humerus inherent, 47 Goal statement, on resume, 211, 212f–214f anatomy of, 103, 104f total, 47 Golgi apparatus, 44 radiographic procedures for, 120–121 Filtration-beam quality, 68 Gonadal shield(ing), 47, 94, 94b Hyaline membrane disease, 131 Financial planning worksheet, 197, 198f Gout, 117 Hydrocephalus, 117 Fingers, radiographic procedures for, 117 Governmental requirements, for continuing Hydrogen peroxide (H2O2), 45 Fixed KVp-variable mAs technique charts, 63 education, 203–205 Hyoid bone, 100 Flat contact shield, 47 Graya, 39 Hypersthenic body habitus, 94 Flat panel image-intensifier, 66 Grayt, 39–40 Hypodermic needle Flexion, 97 Great saphenous vein, 111 gauge of, 16 Floating ribs, 103 Greater sciatic notch, 103 use of, 30 Fluoroscopy, 65–67, 67b Greater wings, of sphenoid bone, 99 Hyposthenic body habitus, 94 equipment for Greenstick fracture, 116 Hypovolemic shock, 16, 27 digital, 66, 67f Grid conversion factor (GCF), 77 Hysterosalpingography, 146 256 Index

I Interview, 217–220 Left lateral decubitus, 91 ICRP. see International Commission on outcomes and follow-up of, 220, 220f, 220b Left lateral recumbent, 91 Radiologic Protection (ICRP) personal appearance at, 217–218 Left posterior oblique (LPO), 91 Ileum, 113 preparation for, 218 Leg Ileus, 140 process of, 218–220 anatomy of, 106 Ilium, anatomy of, 103 purpose of, 217 radiographic procedures for, 124, 124f Image identification, 9 questions to ask during, 218b Legionnaires’ disease, 131 Image production, 58–90 questions you may be asked during, 218 Length, 58 challenge tests on, 157–159, 171–174, 172f, appropriate, 219, 219b Lesser wings, of sphenoid bone, 99 186–189 inappropriate, 219, 219b LET. see Linear energy transfer (LET) contrast and, 74–75 Intravenous (IV) catheter, 16 Libel, 15, 17 digital image, 68–79 Intravenous urography, 144, 144f Licensure, 203 artifacts, 71–72 Intussusception, 140 Life span, shortening of, 46 computed radiography for, 68–69, 68f Invasion of privacy, 15, 17 LIH. see Last image hold (LIH) digital radiography for (DR), 69, 69f Inventory, task, 221–223 Line focus principle, 62 image characteristics, 71–72, 72b Inverse square law, and digital image receptor Line voltage compensation, 59 imaging informatics as, 69–70 exposure, 58, 73 Linear energy transfer (LET), 39–40 properties of, 72–74 Involuntary motion, 93 Linear grids, 77 workstation monitors as, 69 Iodinated contrast agents Linear-nonthreshold relationship, 43, 43f distortion and, 76, 76b ionic, 16, 29 Linear-threshold relationship, 43, 43f grids in, 73, 76–79, 76f, 78b nonionic, 16, 29 Lines, 93 review questions, 79–85 patient care after injection, 29 Liver, 114 spatial resolution in, 75–76, 75b patient care following injection, 29–30 Long bone radiography, 95 window level in, 71 IOML. see Infraorbitomeatal line (IOML) Longitudinal fissure, 108 window width in, 71 Ionic contrast agents, 29 Look-up table (LUT), 71 Image production and evaluation, 9 Ionization, 58 Lordosis, 102 Image receptor, artifacts related to, 71–72 Ionizing radiation, 39, 41, 41b, 58 Lower extremity Image receptor exposure, digital, 72–74, 73b biological effects of, 45 anatomy of, 103–108 controlling and influencing factors of, 72–74 Irritable bowel syndrome, 140 veins of, 111 Image-intensifier, 66, 66f Ischium, 103–105 Lower gastrointestinal system, radiographic on ABC, 68 Isolation precautions, 24 procedures for, 142–143 flat panel, 66 Isolation technique, 25–26 LPO. see Left posterior oblique (LPO) Image-producing radiation, 39, 41 Isotopes, 58 Lumbar spine Imaging informatics, 69–70 anatomy of, 101 Imaging manager, 208 J topography of, 93 Imaging plate (IP), in computed radiography, 68 Jefferson fracture, 116 Lumbar vertebrae Imaging specialties, 207 Jejunum, 113 radiographic procedures for, 128–130, 129f Immobilization, in pediatric radiography, 94–95 Job application, 216 superoinferior projection of, 161f Implied consent, 15, 18 Joints, 97 Lungs, 112 Imprisonment, false, 15, 17 Jugular foramen, 99 LUT. see Look-up table (LUT) Incomplete fracture, 116 Jugular notch, anatomy of, 102 Lymph, 111 Incomplete statement, 13 Jugular veins, 111 Lymph nodes, 111 Indirect contact transmission, 15 Lymphatic system, 111 Indirect effect, 40 K Lymphocytes, 111 Infection control, 7, 24–26 Kidneys, anatomy of, 114, 115f Lymphoid tissue, 111 cycle of, 7 Kilovoltage peak (kVp) Lysosomes, 44 gloving for, 25 digital image receptor exposure and, 72–73 isolation technique for, 25–26 subject contrast and, 74, 74f–75f M key review points on, 26b Kinetic energy, 58 mA control (filament control), 61 medical asepsis for, 24 Knee Magnetic field, 59 routes of transmission and, 24 AP projection of, 162f Magnetic poles, 59 standard precautions for, 24 radiographic procedures for, 124, 125f Magnetics, laws of, 59 sterile techniques for, 25 Kyphosis, 102 Malpractice, conditions needed to establish, 17 surgical asepsis for, 24–25 Mandible Infection control barriers, 15 L anatomy of, 100, 100f Infectious waste, handling and disposal of, 31–32 Laboratory assistant, 208 radiographic procedures for, 138 Inferior mesenteric artery, 110 Lacrimal bone, 100 Mandibular fossa, 99 Inferior nasal concha, 100 LAO. see Left anterior oblique (LAO) Manubrial notch, 102 Inferior vena cava, 111 Large bowel obstruction, 140 Manubrium, anatomy of, 102 Informed consent, 15 Large intestine, anatomy of, 114 Marrow, 96 Infraorbitomeatal line (IOML), 91, 93 Laryngopharynx, 112 Mass, 58 Inherent filtration, 47 Larynx, 112 atomic, 58 Innominate bone, 103–105, 106f Last image hold (LIH), 48 Master’s degrees, 208, 209b Input phosphor, 66, 66f Late somatic effects of radiation, 40, 46 Material safety data sheets (MSDS), 16 Inspiration, 112 Lateral, 91 Matrix, 71 as markers, 93 Lateral decentering grid, 78 Matrix size, 71 Instructor, 208 Lateral epicondyle, of humerus, anatomy of, 103 Matter, 58 Insulator, 59 Law of Bergonié and Tribondeau, 40, 45 law of conservation of, 58 Intentional misconduct, 17 Law of conservation of energy, 58 Maxilla, anatomy of, 99–100 Internal iliac artery, 110 Law of conservation of matter, 58 Maxillary sinus, anatomy of, 100 Internal jugular vein, 111 Laws of electrostatics, 59 Mean marrow dose, 40, 48 Internal markers, 93 Laws of magnetics, 59 Meatus, 96 International Commission on Radiologic Lead apron, 49 Medial, 91 Protection (ICRP), 39, 42–43 Left anterior oblique (LAO), 91 Medial epicondyle, of humerus, anatomy of, 103 Interphase, 44 Left gastric artery, 110 Median sagittal plane (MSP), 91, 95 Index 257

Mediastinum, 109 Natural background radiation, 41 P Medical asepsis, 15, 24 Negative contrast agent, 29 PACS. see Picture archiving and communications Medical background radiation, 41 Negligence, 15, 17 system (PACS) Medical emergencies, 27–28 contributory, 17 Paget’s disease, 117 Medicolegal aspects, of practice, 17–19 gross, 17 Pair production, 42 key review points on, 21b–22b Nerve cell, 108 Palatine bones, 100 Medulla, 114 Nerve tissue, adult, radiosensitivity of, 46 Pancreas, 114 Medulla oblongata, 108 Nervous system, 108–109 Paranasal sinuses, radiographic procedures for, Meiosis, 44 Neurogenic shock, 16 138–139, 139f Meninges, 108–109 Neuron, 108 Parietal bones, anatomy of, 97 Mental foramen, 100 No code, 18 Parietal lobe, 108 Mesencephalon, 108 Non-digital fluoroscopy, 65 Parotid glands, 112 Mesocephalic skull, 97 Nonionic contrast agents, 29 Particulate radiation, 58 Metacarpal bones, anatomy of, 103 Nonlinear-nonthreshold relationship, 43, 43f Patella Metaphase, 44 Nonlinear-threshold relationship, 43, 43f anatomy of, 106 Metaphyseal plate, 96 Nonverbal communication, 15–16 radiographic procedures for, 124–125, 125f Metatarsals, anatomy of, 108 NRC. see Nuclear Regulatory Commission Pathologic fracture, 116 Midcoronal plane, 91, 95–96 (NRC) Pathology Midsagittal plane, 95 Nuclear energy, 58 contrast and, 74 Milliammeter (mA meter), 61 Nuclear medicine, 206 digital image receptor exposure and, 73 Milliampere-second (mAs), and digital image Nuclear Regulatory Commission (NRC), Patient assessment, for changing conditions, 26–28 receptor exposure, 72 39, 43 key review points on, 28b–29b Milliampere-second (mAs) timer, 60 Nucleus in medical emergencies, 27–28 Minification gain, 66 anatomic, 58 patient monitoring and support equipment Minimizing patient exposure, in radiation of cell, 44 for, 28 protection, 8 Numeric markers, 93 vital signs for, 26–27 Misconduct Nyquist frequency, 75 Patient care, 6–11, 15–38 intentional, 17 assessment of changing patient conditions in, unintentional, 17 O 26–28 Mission statement, of American Registry of Object to image receptor distance (OID), and complications and reactions to, 30 Radiologic Technologists, 19b–21b spatial resolution, 75 key review points, 28b–29b Mitochondria, 44 Oblique, 91 in medical emergencies, 27–28 Mitosis, 44 Oblique cervical spine, 162f patient monitoring and support equipment Mobile radiographic units, 67, 67b Oblique fracture, 116 for, 28 Mobile radiography Obturator foramen, 105 vital signs for, 26–27 isolation technique for, 25–26 Occipital bone, anatomy of, 99 basic care terminology for, 15 patients in radiology departments, 26 Occipital condyles, 99 challenge tests on, 166–168, 181–183, patients with neutropenia, 26 Occipital lobe, 108 192–194 Monitoring Occupancy, and barrier thickness, 50 communication with patient in, 16–17 patient, 28 Occupational Safety and Health Administration key review points on, 17b of radiation exposure, 51, 51b (OSHA), 16 for contrast media, 29–30 to area, 51 Octet rule, 58 key review points on, 30b to personnel, 51 OER. see Oxygen enhancement ratio (OER) hazardous materials in, 31–32, 32f Motion Off-level grid, 78 handling and disposal of, 31–32, 31f involuntary, 93 Ohm’s law, 59 key review points on, 32b spatial resolution and, 75 OML. see Orbitomeatal line (OML) infection control in, 24–26 voluntary, 93–94 Optically stimulated luminescence (OSL) gloving for, 25 Motion control, 93–94, 94b dosimeters, 51 isolation technique for, 25–26 Mouth, 112 Orbit key review points on, 26b Movements, 97 anatomy of, 99f medical asepsis for, 24 Moving grids, 77 radiographic procedures for, 135, 136f routes of transmission and, 24 MSDS. see Material safety data sheets (MSDS) Orbitomeatal line (OML), 91, 93 standard precautions for, 24 MSP. see Median sagittal plane (MSP) Organizational structure, 223–227 sterile techniques for, 25 Multiple myeloma, 117 Oropharynx, 112 surgical asepsis for, 24–25 Muscle, radiosensitivity of, 45 Os coxae, 103–105 interactions and management, 6–7 Mutation, 40, 45 OSHA. see Occupational Safety and Health ethical and legal aspects of, 6 Mutual induction, 59 Administration (OSHA) handling and disposal of toxic/hazardous Myelin sheath, 108 Osseous matrix, 96 material, 7 Myelography, 145 Ossification, 96 infection control, 7 Myocardium, 109 Osteitis deformans, 117 interpersonal communication of, 6–7 Osteoarthritis, 117 medical emergencies, 7 N Osteoblastic metastases, 117 pharmacology, 7 Nasal bones Osteochondroma, 117 physical assistance and monitoring, 7 anatomy of, 100 Osteogenesis imperfecta, 117 safety, 7–8 radiographic procedures for, 136–137 Osteogenic sarcoma, 117 medicolegal aspects of practice, 17–19 Nasal cavity, 111 Osteolytic metastases, 117 key review points on, 21b–22b Nasogastric (NG) tubes, 16, 28 Osteoma, 117 patient comfort in, 23 Nasopharynx, 111 Osteomalacia, 117 patient history in, 22–23, 23b National Academy of Sciences/National Research Osteomyelitis, 117 patient preparation in, 22 Council Committee on the Biological Effects Osteopetrosis, 117 key review points on, 22b of Ionizing Radiation (NAS/NRC-BEIR), 39 Osteoporosis, 117 patient transfer in, 23 National Council on Radiation Protection and Ova, radiosensitivity of, 46 cart, 23 Measurements (NCRP), 39, 43 Overdose, of contrast agents, 30 key review points on, 24b report #102, 39 Oxygen administration, 15, 27 from wheelchair to x-ray table, 23 report #116, 39, 43–44 Oxygen enhancement ratio (OER), 45 from x-ray table to wheelchair, 23 258 Index

Patient care (Continued) Pneumoconiosis, 131 Procedures (Continued) review questions of, 32 Pneumonia, 131 for foot, 122–123, 123f scheduling of radiographic examinations in, Pneumothorax, 131 for forearm, 119, 119f–120f 22, 22b PNS. see Peripheral nervous system (PNS) for hand, 118 venipuncture in, 30–31 Polycystic kidney disease, 960 for hip, 126, 126f key review points on, 31b Popliteal vein, 111 for humerus, 120–121 Patient comfort, 23 Position, 91 for knee, 124, 125f Patient education, 15–17 Positive beam limitation (PBL), 47 for leg, 124, 124f Patient exposure and protection, 47–49, 49b Positive contrast agent, 16, 29 for lumbar vertebrae, 129f for air kerma, 48 Posterior, 91 for patella, 124–125, 125f beam limitation and, 47 Postprocessing, 71 for pelvis, 126 exposure factors, 47–48 Potential energy, 58 for sacroiliac joints, 130 filtration and, 47 Pott’s fracture, 116 for sacrum, 130 for fluoroscopy, 48 Power, 58 for scapula, 122, 122f gonadal shields and, 47 PPE. see Personal protective equipment (PPE) for scoliosis series, 130 grids and, 48 Precautions for shoulder, 121, 121f with repeat exposures, 48 additional, 7 for thoracic vertebrae, 127–128, 128f–129f technical standards for, 48 airborne, 15, 25 for thumb, 118 Patient history, 15, 22–23, 23b contact, 15, 25 for toes, 122 Patient identification, 92 droplet, 15, 25 for wrist, 118–119, 118f–119f Patient monitoring, 28 standard, 15 terminology in, 91, 92b Patient preparation, 22 transmission-based isolation, 24 for thorax, 130–139 key review points on, 22b Precise visualization, 92 for chest, 131–133, 132f Patient support equipment, 28 Prefixes, 92 for cranium, 134, 134f–136f Patient transfer, 23 Prefrontal area, 108 for facial bones, 136, 137f cart, 23 Prereading voltmeter, 60 for mandible, 138 key review points on, 24b Primary bronchi, 112 for nasal bones, 136–137 from wheelchair to x-ray table, 23 Primary radiation, 39, 41 for orbit, 135, 136f from x-ray table to wheelchair, 23 Prioritization, of study topics, 2–6 for paranasal sinuses, 138–139, 139f Patient’s bill of rights, 18 Privacy, invasion of, 15, 17 for ribs, 133 Patient’s rights, 18–19 Probabilistic effects, 39, 43 for skull, 134–139 PBL. see Positive beam limitation (PBL) Probationary status, for noncompliance with for sternoclavicular joints, 133 Pediatric radiography, 94–95, 95b continuing education requirements, 204 for sternum, 133, 133f Pelvic region, topography of, 93 Procedures, 91–153 for temporomandibular articulations, 138 Pelvis anatomy in, 95–116, 116b for zygomatic arches, 137–138 anatomy of, 105 of abdomen, 96 topography in, 93, 93b radiographic procedures for, 126 of digestive system, 112–114 for trauma, 95, 95b Penalties, for noncompliance with continuing of heart, 109–111 for urinary system, 143–146 education requirements, 204 of lymphatic system, 111 cystography, 144–145 Peptic ulcer disease, 965 of nervous system, 108–109 cystourethrography, 144–145 Peripheral nervous system (PNS), 108 planes of the body in, 95–96 intravenous urography, 144, 144f Perpendicular plate, 99 of respiratory system, 111–112 retrograde pyelography, 145, 145t Personal appearance, at interview, 217–218 of skeletal system, 96–108 Process, 96 Personal data, on resume, 211, 212f–214f of urinary system, 114–116 Professional accomplishments, on resume, Personal protective equipment (PPE), 16 basic principles of, 92–93, 93b 212f–214f, 215 Personnel exposure, monitoring of, 51 body habitus in, 94, 94b Professional associations, on resume, 212f–214f, 215 Personnel monitoring devices, 40 exposure modification in, 94, 94b Professional credentials, on resume, 212f–214f, 215 Personnel protection, in radiation protection, 8–9 for gastrointestinal system, 140–146 Professional judgment, in using social media, 224 Phalanges for abdomen, 140, 141f Professional requirements, for continuing of foot, 108 for colon, 142–143, 142f education, 203–205 of hand, 103 endoscopic retrograde Professional responsibility, organizational structure Pharmacology, 29–30 cholangiopancreatography, 143 and, 223–227 Pharyngeal tonsils, 111 for esophagus, 140–141 Program director, 208 Pharynx, 111–112 general survey exams in, 140 Projection, 91 Photodisintegration, 42 lower, 142–143 of bones, 96 Photoelectric effect, 39, 41, 42f for small bowel, 142 Prophase, 44 Photoelectric interaction, 41, 42f for stomach, 141–142, 141f Protective curtain, for fluoroscopy, 50 Photoelectron, 41 for surgical cholangiogram, 143 Proximal, 91 Photon, 58 upper, 140–142 PSP. see Photostimulable phosphor (PSP) Photon interactions with matter, 8 gonadal shielding in, 94, 94b Psychogenic factors, in reactions to contrast Photon-tissue interactions, 41–42, 42f, 42b imaging, challenge tests on, 160–166, 160f–166f, agents, 16, 30 Photostimulable phosphor (PSP), 68 174–181, 175f–179f, 189–192 Pubic bone, 103 Physicians, expectations of, 224 motion control in, 93–94, 94b Pulmonary metastases, 131 Pia mater, 109 pediatric radiography in, 94–95, 95b Pulmonary veins, 111 Picture archiving and communications system radiographic, 116–146, 146b Pulse, 15, 26 (PACS), 69 for skeletal system, 116–130 Pyelonephritis, 143 Pivot joint, 97 for acromioclavicular articulations, 121 Pyloric stenosis, 140 Pixel, 71 for ankle, 123–124, 123f–124f Pixel density, 71 for calcaneus, 123 Q Pixel pitch, 71 for cervical vertebrae, 126–127, 126f–128f Quadrants, of abdomen, 96 and spatial resolution, 75 for clavicle, 122 Quality assurance, 67 Pixel size, and spatial resolution, 75 for coccyx, 130 Quality control, 68 Planes of the body, 95–96 for digits, 117 of digital imaging equipment, 70 Pleura, 112 for elbow, 119–120, 120f of imaging equipment and accessories, 10 Pleural effusion, 131 for femur, 125–126 of x-ray producing equipment, 67–68, 68b Index 259

Quantum mottle, 71 Radiation protection (Continued) Resolution Questions radiosensitivity of, 45–46 contrast, 74 to ask during interview, 218b responsibility for, 40–41 spatial, 75–76, 75b direct, 13 review questions for, 51 controlling and influencing factors on, 75–76 you may be asked during interview, 218 units of radiation measurement in, 40, 40b Respiration, 26 appropriate, 219, 219b Radiation therapy technology, 206–207 assessment of, 26 inappropriate, 219, 219b Radiation weighting factor (WR), 40 defined, 15 Radiation worker exposure and protection, mechanics of, 112 R 49–51, 50b Respiratory arrest, 16, 27 Radial artery, 110 cardinal principles of, 40, 49 Respiratory bronchioles, 112 Radiation with fluoroscopic equipment, 50 Respiratory rate, 26 artificially produced, 39 with portable radiographic equipment and Respiratory system, 111–112 background procedure, 50–51 Respiratory tract, 111 medical, 41 sources of exposure and, 49–50 Respondeat superior, 15, 17, 33 natural, 39, 41 structural protective barriers for, 50 Results, of examination, 14 Bremsstrahlung (brems), 63, 63f x-ray tube housing for, 50 Resume, 210–216 characteristic of, 64, 64f Radioactivity, unit of, 40 appearance of, 215–216 early somatic effects of, 40, 46 Radiographer, and patient protection, 40 contents of, 210–211 exit (remnant, image-producing), 39, 41 Radiographic examinations, scheduling of, 22, 22b cover letter for ionizing, 39, 41, 41b, 58 Radiographic images appearance of, 215–216 biological effects of, 45 geometric properties, effect of variables on, for general mailing, 210, 210f late somatic effects of, 40, 46 79t in response to job posting, 215, 215f primary, 39, 41 medicolegal aspects of, 18–19 education on, 212f–214f, 215 units of measurement for, 40, 40b Radiographic quality employment experiences on, 211, 212f–214f Radiation exposure factors affecting, 9 goal statement on, 211, 212f–214f monitoring of, 51, 51b technique charts of, 9 job application and, 216 to area, 51 Radiography educator, 207–208 key points on, 216b to personnel, 51 Radiologic specialties, 205–208 personal data on, 211, 212f–214f to patient, 47–49, 49b diagnostic medical sonography as, 205–206 professional accomplishments, associations, and for air kerma, 48 as imaging manager, 208 credentials on, 212f–214f, 215 beam limitation and, 47 key points on, 209b purpose of, 210 exposure factors, 47–48 nuclear medicine as, 206 references on, 212f–214f, 215 filtration and, 47 other, 207 sample, 211, 212f–214f to fluoroscopy, 48 radiation therapy technology as, 206–207 Retrograde pyelogram, 160f gonadal shields and, 47 as radiography educator, 207–208 Retrograde pyelography, 145, 145t grids and, 48 as radiologist assistant, 207 Review with repeat exposures, 48 Radiologist assistant, 207 determining length of, 2–3 technical standards for, 48 Radiologists, expectations of, 224 key points, 6b to radiation worker, 49–51, 50b Radiology information system (RIS), 69 planning process of, 3–4 cardinal principles of, 40, 49 Radiology manager, expectations of, 224–225 preparation for, 1–14 with fluoroscopic equipment, 50 Radiolysis, of water, 40, 45 prioritization of study topics for, 2–6 with portable radiographic equipment and Radiosensitivity, 8 scheduling study time, 4–5, 4f procedure, 50–51 of cells, 45–46 strongest subjects, 3 sources of, 49–50 Radius, anatomy of, 103 study habits for, 5 structural protective barriers for, 50 RAO. see Right anterior oblique (RAO) weakest subjects, 3 x-ray tube housing for, 50 RBE. see Relative biologic effectiveness (RBE) weakest to strongest topics, 3–4 Radiation physics, principle of, 7–8 RCEEM. see Recognized Continuing Education Rheumatoid arthritis, 117 Radiation protection Evaluation Mechanism (RCEEM) Ribosomes, 44 annual dose limits in, 42–44, 44b Reasonably prudent person doctrine, 17 Ribs basic principles of, 40–41 Recognized Continuing Education Evaluation anatomy of, 102–103 cardinal principles of, 40, 49 Mechanism (RCEEM), 204 radiographic procedures for, 133 cells and, 44, 46b Recoil electron, 42 Rickets, 117 biological effects of ionizing radiation, 44 Rectification, 59 Right anterior oblique (RAO), 91 division of, 44 full-wave Right lateral decubitus, 91 genetic effects of radiation on, 46–47 with 6-12 diodes, for three-phase Right lateral recumbent, 91 somatic effects of radiation on, 46 equipment, 61 Right lymphatic duct, 111 for patient, 47–49, 49b with four diodes, for single-phase Right posterior oblique (RPO), 91 for air kerma, 48 generator, 61 RIS. see Radiology information system (RIS) beam limitation and, 47 Rectifier, 61 Roots, 92 exposure factors, 47–48 Rectum, 114 Rotation, 97 filtration and, 47 cancer of, 960 Routines, 93 to fluoroscopy, 48 Red bone marrow, 96 RPO. see Right posterior oblique (RPO) gonadal shields and, 47 Reduction division, 44 Rules of Ethics, of American Registry of grids and, 48 References, on resume, 212f–214f, 215 Radiologic Technologists, 19b–21b with repeat exposures, 48 Referring physicians, expectations of, 224 technical standards for, 48 Relative biologic effectiveness (RBE), 39, 45 S photon-tissue interactions and, 41–42, 42f, 42b Remnant radiation, 39, 41 Sacral vertebrae, anatomy of, 101 for radiation worker, 49–51, 50b Renal artery, 110 Sacroiliac joints, radiographic procedures for, 130 cardinal principles of, 40, 49 Renal calculus, 143 Sacrum with fluoroscopic equipment, 50 Renal carcinoma, 143 radiographic procedures for, 130 with portable radiographic equipment and Renal cysts, 960 region of, topography of, 93 procedure, 50–51 Replication division, 44 Saddle joint, 97 sources exposure and, 49–50 Reproductive cells, radiosensitivity of, 46 Safety, 39–57 structural protective barriers for, 50 Res ipsa loquitur, 15, 17 challenge tests on, 154–157, 168–171, 183–186 x-ray tube housing for, 50 Resistance, electrical, 59 Sagittal plane, 91, 95 260 Index

Saliva, 112 Skull (Continued) Sternoclavicular joints, radiographic procedures Salivary glands, 112 sphenoid bone in, 99 for, 133 Scapula temporal bones in, 97–99 Sternocostal articulations, 102f anatomy of, 103, 104f brachycephalic, 97 Sternum radiographic procedures for, 122, 122f dolichocephalic, 97 anatomy of, 102 Scatter injuries of, 95 radiographic procedures for, 133, 133f coherent, 42 lateral projection of, 165f Sthenic body habitus, 94 Compton, 41, 42f mesocephalic, 97 Stochastic effects, 39, 43 Scheduling radiographic procedures for, 134–139 Stomach of radiographic examinations, 22, 22b Slander, 15, 17 anatomy of, 113, 113f study time, 4–5, 4f Small bowel obstruction, 140 AP projection of, 161f Scoliosis, 102, 117 Small intestine radiographic procedures for, 141–142, 141f radiographic procedures for, 130 anatomy of, 113 Stress fracture, 116 Seat belt fracture, 117 radiographic procedures for, 142 Structural protective barriers, for radiation Secondary bronchi, 112 Small saphenous vein, 111 worker, 50 Self-induction, 59 Social media, professional judgment in using, 224 determinants of, 50 Sella turcica, 99 Software, artifacts related to, 72 primary, 50 Semiconductor, 59 Solenoid, 59 secondary, 50 Septic shock, 16, 27 Somatic effects, 8, 39, 46 x-ray tube housing for, 50 Shadow shield, 47 early, 40, 46 Students under supervision, expectations of, Shape distortion, 76, 76f late, 40, 46 225–226 Shielding, 49 Somesthetic area, 108 Study calendar, 3, 4f Shields Sonography, diagnostic medical, 205–206 Study habits, 5 Bucky slot, 50 Source-to-image receptor distance (SID), and Styloid process, 99 flat contact, 47 spatial resolution, 75 Subarachnoid space, 109 gonadal, 47 Spatial frequency resolution, 71 Subclavian arteries, 110 shadow, 47 Spatial resolution, 75–76, 75b Subject contrast, 74, 74f–75f Shock, 16, 27 controlling and influencing factors on, 75–76 Sublingual glands, 112 allergic, 16, 27 Specialties, 205–208 Subluxation, 116 cardiogenic, 16, 27 diagnostic medical sonography as, 205–206 Submandibular glands, 112 hypovolemic, 16, 27 as imaging manager, 208 Subtraction, 71 neurogenic, 16, 27 key points on, 209b Suction unit, 16, 27 septic, 16, 27 nuclear medicine as, 206 Suffixes, 92 Shoulder other, 207 Sulcus, 96 anatomy of, 103 radiation therapy technology as, 206–207 Superior mesenteric artery, 110 AP projection of, 164f as radiography educator, 207–208 Superior orbital fissure, 99 radiographic procedures for, 121, 121f as radiologist assistant, 207 Superior vena cava, 111 SI system, 58 Speed of travel, 58 Support equipment, 28 SI units of measurement, 8 Sperm cells, immature, radiosensitivity of, 46 Suprapubic catheter, 28 Siderosis, 131 Sphenoid bone, anatomy of, 99 Suprarenal artery, 110 Sievert, 39–40 Sphygmomanometer, 15 Surgical asepsis, 15, 24–25 Sigmoid colon, 114 Spina bifida, 117 Surgical cholangiogram, 143 Silicosis, 131 Spine, 96 Swallowing, 113 Sine waves, 58–59 cervical Symphysis pubis, 103 Single-phase, two-pulse alternating current, 59 anatomy of, 100–101 Synarthroses, 97 Sinus, 96 injuries in, 95 Synovial joints, 97 Size distortion, 76 topography of, 93 Systolic pressure, 15, 26 Skeletal system iliac, anterior inferior, 103 anatomy of, 96–108 lumbar T appendicular skeleton in, 103–108 anatomy of, 101 Tachycardia, 15 articulations in, 97 topography of, 93 Talipes, 116 axial skeleton in, 97–103 thoracic Talus, anatomy of, 106 bones in, 96 anatomy of, 101 Tangential, 91 bones of thorax in, 102–103 topography of, 93 Target interactions, 8 division of, 96–97 Spinous process, 100 Target theory, 45 facial bones in, 99–100 Spiral fracture, 116 Task inventory, 6, 221–223 lower extremity in, 103–108 Spleen, 111 Technical errors, artifacts related to, 72 marrow in, 96 Splenic artery, 110 Telophase, 44 ossification in, 96 Splints, 95 Temperature, 15, 26 skull in, 97–99, 98f Spondylolisthesis, 117 Temporal bones, anatomy of, 97–99 skull morphology in, 97 Spondylolysis, 117 Temporal lobe, 108 upper extremity in, 103 Squamous portion, 97 Temporomandibular articulations, radiographic vertebral column in, 100–102 Standard of ethics, of American Registry of procedures for, 138 functions of, 96 Radiologic Technologists, 19 Terminal bronchioles, 112 Skeleton Standard precautions, 15 Tertiary bronchi, 112 appendicular, 97, 103–108 State accreditation, 203 Test items, 13 axial, 97–103 State licensure, 203 Test-taking skills, 12–14 division of, 96–97 Stationary grids, 77 Thermal energy, 58 Skull Stem, of test item, 13 Thermionic emission, 62 anatomy of, 97–99, 98f Step-down transformer, 59 Thermoluminescent dosimeters (TLDs), 51 cranium in, 97 Step-up transformer, 59, 61 Thoracic aorta, 110 ethmoid bone in, 99 Sterile technique, 25 Thoracic duct, 111 frontal bone in, 97 Sterilization Thoracic spine occipital bone in, 99 chemical, 24 anatomy of, 101 parietal bones in, 97 gas, 25 topography of, 93 Index 261

Thoracic vertebrae, radiographic procedures for, Tuberosity, 96 Voltmeter, prereading, 60 127–128, 128f–129f Tutorial, 13 Voluntary motion, 93–94 Thorax Volvulus, 140 bones of, 102–103 U Vomer, anatomy of, 100 radiographic procedures for, 130–139 Ulcerative colitis, 960 Three-phase alternating current, 59 Ulna, anatomy of, 103 W Thumb, radiographic procedures for, 118 Ulnar artery, 110 Water, radiolysis of, 40, 45 Thymus, 111 Uncontrolled area, 50 Wave-particle duality, 58 Thyroid, effects of radiation on, 46 Undisplaced fracture, 116 Wheelchair Tibia, anatomy of, 106, 106f Unintentional misconduct, 17 transfer from, 23 Time Units of radiation measurement, 40, 40b transfer to, 23 administrators and, 224 Upper extremity, anatomy of, 103 Wilms’ tumor, 144 indicators, 92 Upper gastrointestinal system, radiographic Window width, 71 and radiation exposure, 49 procedures for, 140–142 Work, 58 Timer, 60–61 Upside down grid, 78 Workforce, entering into, 221 electronic, 60 Ureters, 114 Workload, 50 mAs, 60 Urethra, 115 WR. see Radiation weighting factor (WR) Tissue density, and contrast, 74 Urinary catheters, 28 Wrist Tissue thickness, and contrast, 74 Urinary system, 114–116 anatomy of, 103, 105f Tissue weighting factor (WT), 40 radiographic procedures for, 143–144 PA radiograph of, 163f TLDs. see Thermoluminescent dosimeters U.S. Departments of Education and Labor, 208 radiographic procedures for, 118–119, 118f–119f (TLDs) Use factor, 50 WT. see Tissue weighting factor (WT) Toes anatomy of, 106–108 V X radiographic procedures for, 122 Valid consent, 18 X-ray beam, 8 Tongue, 112 Valves, 111 characteristics, 64–65 Tonsils, 111 Variable KVp-fixed mAs technique charts, 63 X-ray control booth, 50 Topography, 93, 93b Variable technique, 63 X-ray emission spectrum, 64 Torts, 15, 17 Vector-borne transmission, 15, 24 continuous, 64 Total filtration, 47 Veins, 109 discrete, 64 Trachea, 112 Velocity, 58 X-ray production, 7, 63–65 Tracheolaryngeal edema, 27 Venipuncture, 30–31 Bremsstrahlung (brems) radiation in, 63, 63f Transfer, 23 key review points on, 31b characteristic radiation in, 64, 64f cart, 23 Venous catheters, 28 conditions necessary for, 60, 65b key review points on, 24b Venous systemic circulation, 110–111 equipment for, 60–62, 60f from wheelchair to x-ray table, 23 Ventilators, 16, 28 automatic exposure control (AEC) as, 60–61 from x-ray table to wheelchair, 23 Ventral, 91 autotransformer as, 60 Transformer, 59 Ventral decubitus, 91 electronic timer as, 60 Transmission Ventral recumbent, 91 falling load generator, 61 airborne, 15, 24 Ventricles, 109 glass envelope with window as, 62 common vehicle, 15, 24 Venules, 109 mA control (filament control) as, 61 contact Verbal communication, 15–16 mAs timer as, 60 direct, 15, 24 Vertebrae milliammeter (mA meter), 61 indirect, 15 anatomy of, 100 prereading voltmeter as, 60 droplet, 15, 24 cervical quality control for, 67–68, 68b routes of, 24 anatomy of, 100–101, 101f rectifier as, 61 vector-borne, 15, 24 radiographic procedures for, 126–127, step-up transformer as, 61 Transmission-based precautions, 7 126f–128f timer as, 60–61 types of, 25 lumbar tube housing as, 62 Transverse arches, 108 anatomy of, 101, 102f x-ray tube as, 62, 62f Transverse colon, 114 radiographic procedures for, 128–130, 129f heat units in, 65 Transverse fracture, 116 morphology of, 100 x-ray beam characteristics, 64–65 Transverse plane, 91, 96 sacral, anatomy of, 101 x-ray properties in, 64 Transverse processes, 100 thoracic X-ray table Trauma anatomy of, 101, 102f transfer from cart to, 23 defined, 16 radiographic procedures for, 127–128, transfer from wheelchair to, 23 patient care for, 27–28 128f–129f transfer to wheelchair from, 23 procedures for, 95, 95b Vertebral artery, 110 X-ray tube, 62, 62f Trimalleolar fracture, 116 Vertebral column, anatomy of, 100–102 X-ray tube housing, 50 Trochanter, 96 Vertebral veins, 111 Trochlea, anatomy of, 103 View, 91 Z Tube window, 62 Visual area, 108 Zygomatic arches, radiographic procedures for, Tubercle, 96 Vital signs, 26–27 137–138 Tuberculosis, 131 Vocal chords, 112 Zygomatic bone, 100