Chapter 7 Anatomy, Positioning, and Pathology

21. Aspirated foreign bodies in older children and adults are most likely to lodge in the (A) right main bronchus (B) left main bronchus (C) esophagus (D) proximal stomach

21. (A) Because the right main bronchus is wider and more vertical, aspirated foreign bodies are more likely to enter it than to the left main bronchus, which is narrower and angles more sharply from the trachea. An aspirated foreign body does not enter the esophagus and/or stom-ach, as they are digestive, not respiratory, structures.

34. Which of the following best describes the relationship between the esophagus and the trachea? (A) Esophagus is posterior to the trachea (B) Trachea is posterior to the esophagus (C) Esophagus is lateral to the trachea (D) Trachea is lateral to the esophagus

34. (A) The trachea (windpipe) is a tube-like passageway for air that is supported by C-shaped cartilaginous rings. The trachea is part of the respiratory system and is continuous with the mainstem bronchi. The esophagus, part of the alimentary canal, is a hollow tube-like structure connecting the mouth and the stomach and lies posterior to the trachea. If one inadvertently aspirates food or drink into the trachea, choking occurs.

4. In the 15°-20° mortise oblique position of the ankle, the 1. talofibular joint is visualized 2. talotibial joint is visualized 3. plantar surface should be vertical (A) 1 only (B) 1 and 3 only (C) 2 and 3 only (D) 1, 2, and 3

4. (D) The medial oblique projection (15°-20° mortise view) of the ankle is valuable because it demonstrates the tibiofibular joint as well as the talotibial joint, thereby visualizing all the major articulating surfaces of the ankle joint. To demonstrate maximum joint volume, it is recommended that the plantar surface be vertical.

48. A postvoid image of the urinary bladder is usually requested at the completion of an intravenous urogram and may be helpful in demonstrating 1. residual urine 2. prostate enlargement 3. ureteral tortuosity (A) 1 only (B) 1 and 2 only (C) 1 and 3 only (D) 1, 2, and 3

48. (B) An AP postvoid bladder image is usually required to detect any residual urine in the evaluation of tumor masses or enlarged prostate glands. An erect image is occasionally requested to demonstrate renal mobility and ureteral tortuosity.

8. The proximal tibiofibular articulation is best demonstrated in which of the following positions? (A) Medial oblique (B) Lateral oblique (C) AP (D) Lateral

8. (A) With the femoral condyles of the affected side rotated medially/internally to form a 45° angle with the IR, the proximal tibiofibular articulation is placed parallel with the IR and the fibula is free of superimposition with the tibia. The lateral oblique projection completely superimposes the tibia and the fibula. The AP and lateral pro-lections superimpose enough of the tibia and the fibula so that the tibiofibular articulation is "closed."

1. In the AP projection of the knee, the 1. patella is visualized through the femur 2. CR is directed ½ inch distal to the patellar base 3. CRis directed 3°-5° cephalad when the distance between the tabletop and the ASIS is 17 cm (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

1. (A) The AP projection of the knee requires the knee to be extended. There should be no pelvic rotation, although the leg may be rotated 3°-5° internally. The central ray is directed to 1/2 inches below patellar apex (location of the knee joint). The direction of the CR depends on the distance between the ASIS and the tabletop; that is, up to 19 cm (thin pelvis) angle 3°-5° caudad; 19-24 cm is 0° (perpendicular) CR; greater than 24 cm (thick pelvis) 3°-5° cephalad. This demonstrates an AP projection of the knee joint, distal femur, and proximal tibia/fibula. The patella is seen through the femur. The femoral condyles are superimposed in the lateral projection of the knee.

10. The scapular Y projection of the shoulder demonstrates 1. a lateral projection of the shoulder 2. anterior or posterior dislocation 3. an oblique projection of the shoulder (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

10. (C) The scapular Y projection requires that the coronal plane be approximately 60° to the IR, thus resulting in an oblique projection of the shoulder. The vertebral and axi - lary borders of the scapula are superimposed on the humeral shaft, and the resulting relationship between e the glenoid fossa and the humeral head will demonstrate anterior or posterior dislocation. Lateral or medial dislocation is evaluated on the AP projection.

11. In the AP axial projection (Towne method) of the skull, with the central ray directed 30° caudad to the OML and passing midway between the external auditory meati, which of the following is best demonstrated? (A) Facial bones (B) Frontal bone (C) Occipital bone (D) Basal foramina

11. (C) The AP axial projection is obtained by angling tie central ray 30° caudad to the OML (Fig. 7-63A). This projects the anterior structures (frontal and facial bones! downward, thus permitting visualization of the occipital bone without superimposition (Towne method). The dor-sum sella and posterior clinoid processes of the sphenoid bone should be visualized within the foramen magnum. The frontal bone is best shown in the PA projection with a perpendicular central ray. The parietoacanthial projection is the single best position for facial bones. Basal foramina are well demonstrated in the submentovertical (SMV) projection.

12. Which of the following is a functional study used to demonstrate the degree of AP motion present in the cervical spine? (A) Open-mouth projection (B) Moving mandible AP (C) Flexion and extension laterals (D) Right and left bending

12. (C) The degree of anterior to posterior motion is occasionally diminished with a "whiplash"-type injury. Anterior (forward, flexion) and posterior (backward, extension) motion is evaluated in the lateral position, with the patient assuming flexion and extension positions as much as possible. Left and right bending images of the vertebral column are frequently obtained to evaluate scoliosis.

13. The AP projection of the coccyx requires that the central ray be directed 1. 15° cephalad 2. 2 inches above the pubic symphysis 3. midline at the level of the lesser trochanter (A) 1 only (B) 2 only (C) 1 and 2 only (D) 1 and 3 only

13. (B) The AP projection of the coccyx requires that the CR be directed 10° caudally and centered to a point 2 inches above the pubic symphysis. The AP projection of the sacrum requires a 15° cephalad angle of the CR, centered to a point midway between the pubic symphysis and the ASIS.

14. Which of the following is (are) demonstrated in the oblique projection of the thoracic spine? 1. Intervertebral joints 2. Zygapophyseal joints 3. Intervertebral foramina (A) 1 only (B) 2 onlv (C) 1 and 2 only (D) 1 and 3 only

14. (B) Intervertebral joints are well visualized in the lateral projection of all the vertebral groups. Thoracic and lumbar intervertebral foramina are well demonstrated in the lateral projection. Thoracic and lumbar zygapophyseal joints are demonstrated in an oblique position - thoracic requires a 70° oblique projection and lumbar requires a 45° oblique projection. Cervical articular facets (forming zygapophyseal joints) are 90° to the MSP and are therefore well demonstrated in the lateral projection. The cervical intervertebral foramina lie 45° to the MSP (and 15°-20° to a transverse plane) and are therefore demonstrated in the oblique position.

15. The thoracic vertebrae are unique in that they participate in the following articulations: 1. costovertebral 2. costotransverse 3. costochondral (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

15. (B) There are 12 thoracic vertebrae, which are larger in size than cervical vertebrae and which increase in size as they progress inferiorly toward the lumbar region. Thoracic spinous processes are fairly long and are sharply angled caudally. The bodies and transverse processes have articular facets for the diarthrotic rib articulations (see Fig. 7-48). These structures form the costovertebral (head of the rib with the body of vertebra) and costotrans-verse (tubercle of the rib with the transverse process of vertebra) articulations. The costochondral articulation describes where the anterior and of the rib articulates with its costal cartilage.

16. In order to demonstrate undistorted air/fluid levels, the CR must always be directed (A) parallel with the long axis of the body/part (B) parallel with the floor (C) perpendicular to the long axis of the body/part (D) perpendicular to the floor

16. (B) Radiography of the paranasal sinuses, and other structures such as the chest, must be performed in the erect position so that any air/fluid levels may be demon-strated. In the paranasal sinuses, the erect position helps distinguish between fluid and other pathology such as polyps. To demonstrate air/fluid levels, the CR must always be directed parallel to the floor, even if the patient is not completely in an erect position (just as in chest radiography). If the CR is angled to parallel the plane of the body, any fluid levels will be distorted or indeed obliterated.

17. All of the following statements regarding the PA projection of the skull, with central ray perpendicular to the IR, are true, except (A) OML is perpendicular to the IR (B) petrous pyramids fill the orbits (C) MSP is parallel to the IR (D) central ray exits at the nasion

17. (C) In the exact PA projection of the skull, the CR is perpendicular and exits the nasion. The petrous pyramids should fill the orbits. If the CR is angled caudally, the petrous pyramids are projected lower in the orbits; at approximately 25°-30° caudal angle, they are projected below the orbits. In the PA projection, the OML must be perpendicular to the IR, or the petrous pyramids will not fill the orbits. The MSP must be perpendicular to the IR, or the skull will be rotated and anatomic details will lose L-R symmetry. The MSP is parallel to the IR in the lateral projection of the skull.

18. Which of the paranasal sinuses is composed of many thin-walled air cells? (A) Frontal (B) Sphenoid (C) Ethmoid (D) Maxillary

18. (C) There are four paired paranasal sinuses: frontal, ethmoidal, maxillary, and sphenoidal (see Fig. 7-69). They vary greatly in their size and shape. The left and right frontal sinuses are usually asymmetrical. They are located behind the glabella and superciliary arches of the frontal bone. The frontal sinuses are not present in young children and generally reach their adult size in the 15th or 16th year. The ethmoid sinuses are composed of 6-18 thin-walled air cells that occupy the bony labyrinth of the ethmoid bone. The ethmoidal sinuses of children are very small and do not fully develop until after the 14th year. The maxillary sinuses (maxillary antra/antra of Highmore) are the largest of the paranasal sinuses and are located in the body of the maxillae. The maxillary antra are particularly prone to infection and collections of stagnant mucus. The maxillary antra reach their adult size around the 12th year. The sphenoid sinuses are located in the body of the sphenoid bone and are usually asymmetrical. They generally reach adult size by the 14th year.

19. The intervertebral joints of the thoracic spine are demonstrated with the (A) midcoronal plane 45° to the R (B) MSP 45° to the IR (C) midcoronal plane 70° to the B (D) MSP parallel to the IR

19. (D) Intervertebral joints are well visualized in the lateral projection of all the vertebral groups. Thoracic and lumbar intervertebral foramina are well demonstrated in the lateral projection. Thoracic and lumbar zygapophyseal joints are demonstrated in an oblique position--thoracic requires a 70° oblique projection and lumbar requires a 45° oblique projection. Cervical articular facets (forming zygapophyseal joints) are 90° to the MSP and are therefore well demonstrated in the lateral projection. The cervical intervertebral foramina lie 45° to the MSP (and 15°-20° to a transverse plane) and are therefore demonstrated in the oblique position.

2. A Colles fracture usually involves the following: 1. transverse fracture of the proximal radius 2. posterior and outward displacement of the hand 3. chip fracture of the ulnar styloid process (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

2. (C) A Colles fracture is often caused by a fall onto an outstretched hand in order to "brake" the fall. As a result, the wrist suffers an impacted transverse fracture of the distal inch of the radius, with displacement of the hand posteriorly (i.e., backward, ~30° and outward, causing the characteristic "dinner fork" deformity seen on x-ray examination. This injury is usually accompanied by a chip fracture of the ulnar styloid process.

20. Which of the following structures is subject to blowout fracture? (A) Ethmoid sinuses (B) Zygomatic arch (C) Mandibular condyle (D) Orbital floor

20. (D) The orbital cavities are formed by seven bones (frontal, sphenoid, ethmoid, maxilla, palatine, zygoma/ malar, and lacrimal). The orbital walls are fragile, and the orbital floor is subject to traumatic blowout fractures-_the second most common facial fracture (nasal fractures being number one). Orbital fractures can be accompanied by injury to adjacent structures-bone, muscle, and other soft tissues. Leakage of air from the adjacent maxillary sinuses can cause orbital edema. Orbital floor fractures can be demonstrated using the parietoacanthial (Waters) pro-jection; CT is often indicated for further evaluation.

22. Which of the following is (are) important when positioning the patient for a PA projection of the chest? 1. The patient should be examined in the erect position 2. Clavicles should be brought above the apices 3. Scapulae should be brought lateral to the lung fields (A) 1 only (B) 1 and 2 only (C) 1 and 3 only (D) 1, 2, and 3

22. (C) The chest should be examined in the erect position whenever possible to demonstrate any air or fluid levels. The shoulders should be relaxed and depressed to move the clavicles below the lung apices. The shoulders should be rolled forward to move the scapulae out of the lung fields.

23. Chest radiography should be performed using 72-inch SID whenever possible in order to 1. visualize vascular markings 2. obtain better lung detail 3. maximize magnification of the heart (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

23. (B) Chest radiographs are obtained in the erect position at 72-inch SID whenever possible. The long SID is easily achieved with a minimum patient exposure owing to the low tissue densities being examined (ribs and lungs). The longer SID minimizes magnification of the heart and provides better visualization of pulmonary vascular markings.

24. Blunting of the costophrenic angles seen on a PA projection of the chest can be an indication of (A) pleural effusion (B) ascites (C) bronchitis (D) emphysema

24. (A) Fluid in the thoracic cavity between the visceral and parietal pleurae is called pleural effusion. In the erect position, fluid gravitates to the lowest point, settling in and "blunting" the costophrenic angles. Ascites is an accumulation of serous fluid in the peritoneal cavity. Bronchitis is an inflammation of the bronchial tubes. Pulmonary emphysema is a chronic pulmonary disease characterized by an increase beyond the normal in the size of air spaces distal to the terminal bronchiole and with destructive changes in the walls of the bronchioles.

25. Which of the following conditions is characterized by "flattening" of the diaphragm? (A) Emphysema (B) Етруета (C) Atelectasis (D) Pneumonia

25. (A) Emphysema is characterized by irreversible trapping of air, which gradually increases and overexpands the lungs, thus producing the characteristic flattening of the diaphragm and widening of the intercostal spaces (see Fig. 7-81). The increased air content of the lungs requires a compensating decrease in technical factors. Empyemo describes pus in the pleural cavity as a result of an infec son of the lungs. Atelectasis is a collapsed or airless lung. toeumonia is an inflammation of the lung, there are more than 50 causes of pneumonia.

26. Inspiration and expiration projections of the chest may be performed to demonstrate 1. pneumothorax 2. presence of a foreign body 3. bronchitis (A) 1 only (B) 1 and 2 only (C) 1 and 3 only (D) 1, 2, and 3

26. (B) Phase of respiration is exceedingly important in thoracic radiography; lung expansion and the position of the diaphragm strongly influence the appearance of the finished radiograph. Inspiration and expiration radiographs of the chest are taken to demonstrate air in the pleural cavity (pneumothorax), to demonstrate degree of diaphragm excursion, or to detect the presence of a foreign body. The expiration image will require a somewhat greater exposure (equivalent of 6-8 kV or more) to compensate for the diminished quantity of air in the lungs.

27. Which of the following criteria are used to evaluate a good PA projection of the chest? 1. Ten posterior ribs should be visualized 2. Sternoclavicular joints should be symmetrical 3. Scapulae should be outside the lung fields (A) 1 and 2 only (B) 1 and 3 only (C) 2 and 3 only (D) 1, 2, and 3

27. (D) To evaluate sufficient inspiration and lung expan-sion, 10 posterior ribs should be visualized. Sternoclavicu-lar joints should be symmetrical; any loss of symmetry indicates rotation. Accurate positioning and selection of technical factors are critical to the diagnostic value of the radiographic images. Even slight rotation or leaning can cause sianificant distortion of the heart size and shape. To visualize maximum lung area, the shoulders are rolled forward to remove the scapulae from the lung fields.

28. All of the following statements regarding respiratory structures are true, except (A) the right lung has three lobes (B) the uppermost portion of a lung is its apex (C) the lobes of the left lung are separated by the horizontal fissure (D) the trachea bifurcates into mainstem bronchi

28. I mainstem bronchi, each entering its respective and Fight mainstem bronchi, each entering is respective lung rum. The left bronchus divides into two parts, one it. each lobe of the left lung; the right bronchus divides no three parts, one for each lobe of the right lung. The lungs have a somewhat conical shape; their narrow upper por. fion is called the apex, and their wide lower portion is the base. Structures such as the mainstem bronchi and du. monary artery and veins enter and leave the lungs at the hilum. The right lung has three lobes; the upper and middle lobes are separated by the horizontal fissure, and the middle and lower lobes are separated by the oblique fissure. The left lung has two lobes; the upper and lower lobes are separated by the oblique fissure (see Fig. 7-76).

29. To demonstrate the pulmonary apices below the level of the clavicles in the AP position, the CR should be directed (A) perpendicular (B) 15°-20° caudad (C) 15°-20° cephalad (D) 40° cephalad

29. (C) When the shoulders are relaxed, the clavicles are usually carried below the pulmonary apices. To examine the portions of lungs lying behind the clavicles, the CRis directed 15°-20° cephalad to project the clavicles above the apices when the patient is examined in the AP position.

3. Which of the following projections require(s) that the humeral epicondyles be superimposed? 1. Lateral thumb 2. Lateral wrist 3. Lateral humerus (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

3. (C) For the lateral projections of the hand, wrist, fore-arm, and elbow, the elbow must be flexed 90° to superimpose the distal radius and ulna and humeral epicondyles. Although a lateral humerus projection can be performed with the elbow flexed, if flexion is not possible, the elbow may remain in the AP position and a transthoracic lateral projection of the upper one-half to two-thirds of the humerus may be obtained. Because a coronal plane passing through the epicondyles (interepicondylar line) is perpendicular to the IR in this position, the epicondyles will be superimposed. To obtain a lateral projection of the thumb (first digit), the patient's wrist must be somewhat internally rotated. Remember that an oblique projection of the thumb is obtained in a PA projection of the hand.

30. Radiographic indications of atelectasis include 1. decreased radiographic density/increased brightness of the affected side 2. elevation of the hemidiaphragm of the affected side 3. flattening of the hemidiaphragm of the affected side (A) 1 only (B) 3 only (C) 1 and 2 only (D) 1 and 3 only

30. (C) Pneumothorax is the presence of air in the pleura cavity. A large pneumothorax is usually accompanied by a partial or comelete arcectasis (collapse of the lung. Radiographic indica, onse cor atelectasis indude an increase in tissue density of the collapsed lung (therefore, decreased image density/increased brightness and elevation of the hemidiaphragm of the affected side. The procedure required to remove significant amounts of air, blood, or other fluids in the pleural cavity is thoracentesis.

31. During IVU, the prone position is generally recommended to demonstrate 1. filling of obstructed ureters 2. the renal pelvis 3. the superior calyces (A) 1 only (B) 1 and 2 only (C) 1 and 3 only (D) 1, 2, and 3

31. (B) The kidneys lie obliquely in the posterior portion of the trunk, with their superior portions angled posterl-orly and their inferior portions and ureters angled anteri-orly. Therefore, to facilitate filling of the most anteriorly placed structures, the patient is examined in the prone position. Opacified urine then flows to the most dependent part of the kidney and ureter--the ureteropelvic region, inferior calyces, and ureters.

32. The contraction and expansion of arterial walls in accordance with forceful contraction and relaxation of the heart is called (A) hypertension (B) elasticity (C) pulse (D) pressure

32. (C) As the heart contracts and relaxes while functioning to pump blood from the heart, those arteries that are large and those in closest proximity to the heart will feel the effect of the heart's forceful contractions in their walls. The arterial walls pulsate in unison with the heart's contractions. This movement may be detected with the fingers in various parts of the body and is referred to as the pulse.

33. Which of the following projections of the abdomen could be used to demonstrate air or fluid levels when the erect position cannot be obtained? 1. AP Trendelenburg 2. Dorsal decubitus 3. Lateral decubitus (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

33. (C) Air or fluid levels will be clearly demonstrated only if the central ray is directed parallel to them. Therefore, to demonstrate air or fluid levels, erect or decubitus positions should be used. A "three-way abdomen" study is often conducted to evaluate possible obstruction or free air or fluid within the abdomen and usually consists of AP recumbent, AP erect, and left lateral decubitus projections of the abdomen.

35. To demonstrate esophageal varices, the patient must be examined in the (A) recumbent position (B) erect position (C) anatomic position (D) Fowler position

35. (A) Esophageal varices are tortuous dilatations of the esophageal veins. They are much less pronounced in the erect position and must always be examined with the Patient in a recumbent position. The recumbent position affords more complete filling of the veins, as blood flows against gravity.

36. The usual preparation for an upper Gl series includes (A) clear fluids 8 h prior to examination (B) NPO after midnight (C) enemas until clear before examination (D) light breakfast at the day of examination

36. (B) The upper GI tract must be empty for best x-ray evaluation. Any food or liquid mixed with the barium sulfate suspension can simulate pathology. Preparation therefore is to withhold food and fluids for 8-9 h before the examination, typically after midnight, as fasting examinations are usually performed first thing in the morning.

37. Which of the following positions would best demonstrate a double-contrast visualization of the left and right colic flexures? (A) left lateral decubitus (B) AP recumbent (C) Right lateral decubitus (D) AP erect

37. (D) To demonstrate structures via double-contrast technique, the barium must be moved away from the area and replaced with air. The AP erect position will accomplish that for both the colic flexures. The erect position allows barium to move downward, whereas air rises to fill the flexures. The decubitus positions are useful to demonstrate the lateral and medial walls of the ascending and descending colon.

38. In which of the following positions are a barium-filled pyloric canal and duodenal bulb best demonstrated during a Gl series? (A) RAO (B) Left lateral (C) Recumbent PA (D) Recumbent AP

38. (A) The RAO position affords a good view of the pyloric canal and the duodenal bulb. It is also a good position for the barium-filled esophagus, projecting it between the vertebrae and the heart. The left lateral projection of the stomach demonstrates the left retrogastric space; the recumbent PA position is used as a general survey of the gastric surfaces, and the recumbent AP position with a slight left oblique affords a double-contrast study of the pylorus and the duodenum.

39. What position is frequently used to project the GB away from the vertebrae in the asthenic patient? (A) RAO (B) LAO (C) Left lateral decubitus (D) PA erect

39. (B) There are four types of body habitus. Listed from largest to smallest, they are hypersthenic, sthenic, hyposthenic, and asthenic. The position, shape, and motility of various organs can differ greatly from one body type to another. The typical asthenic GB is situated low and medial, often very close to the midline. To move the GB away from the midline, the LAO position is used. - The GB of hypersthenic individuals occupies a high lateral and transverse position.

40. Which of the following barium/air-filled anatomic structures is best demonstrated in the RAO position? (A) Splenic flexure (B) Hepatic flexure (C) Sigmoid colon (D) Ileocecal valve

40. (B) In the prone oblique positions (RAO/LAO), the flexure disclosed is the one closer to the IR. Therefore, the RAO position will open up the hepatic flexure. The AP oblique positions (RPO/LPO) demonstrate the side away from the IR.

41. In what order should the following studies be conducted? 1. Barium enema 2. Intravenous urogram 3. Upper GI (A) 3, 1, 2 (B) 1,3,2 (C) 2,1,3 (D) 2, 3, 1

41. (C) When scheduling patient examinations, it is important to avoid the possibility of residual contrast medium covering areas of interest on later examinations. The intravenous urogram should be scheduled first because the contrast medium used is excreted rapidly. The BE should be scheduled next. The Gl series is scheduled last. Any barium remaining from the previous BE should not be enough to interfere with the stomach or duodenum, although a preliminary scout image should be taken in each case.

42. All of the following statements regarding the urinary system are true, except (A) the left kidney is usually higher than the right (B) the kidneys move inferiorly in the erect position (C) the upper, expanded part of the ureter is the hilum (D) vessels, nerves, and lymphatics pass through the renal hilum

42. (C) The major components of the urinary system are the kidneys, ureters, and bladder. The tiny functional units within the renal substance are nephrons. The kidneys are retroperitoneal structures held in position by adipose tissue. They are located between the vertebral levels of T12 and L3. The right kidney is usually 1-2 inches lower than the left because of the presence of the liver on the right. The kidneys move inferiorly 1-3 inches when the body assumes an erect position; they move inferiorly and superiorly during respiration. The slit-like opening on the medial concave surface of each kidney is the hilum, which opens into a space called the renal sinus (see Fig. 7-102). The renal artery and vein, lymphatic vessels, and nerves pass through the hilum. The upper, expanded portion of the ureter is called the renal pelvis, or infundibulum, and also passes through the hilum; it is continuous with the major and minor calyces within the kidney.

43. Which of the following examinations require(s) restriction of the patient's diet? 1. GI series 2. Abdominal survey 3. Urogram (A) 1 only (B) 1 and 2 only (C) 1 and 3 only (D) 1, 2, and 3

43. (C) A patient having a Gl series is required to be NO (nothing by mouth) for at least 8 h prior to the examina-tion; food or drink in the stomach can simulate disease. A patient scheduled for a urogram must have the preceding meal withheld so as to avoid the possibility of aspirating vomitus in case of allergic reaction. An abdominal survey does not require the use of contrast medium, and no patient preparation is required.

44. During a Gl examination, the AP recumbent projection of a stomach of average size and shape will usually demonstrate 1. barium-filled fundus 2. double-contrast visualization of distal stomach portions 3. barium-filled duodenum and pylorus o (A) 1 only (B) 1 and 2 only (C) 1 and 3 only (D) 1, 2, and 3

44. (B) With the body in the AP recumbent position, barium flows easily into the fundus of the stomach, displacing it somewhat superiorly. The fundus, then, is filled with barium, whereas the air that had been in the fundus is displaced into the gastric body, pylorus, and duodenum, illustrating them in double-contrast fashion. Air-contrast delineation of these structures allows us to see through the stomach to retrogastric areas and structures. Barium-filled duodenum and pylorus are best demonstrated in the RAO position.

45. Which of the following examinations require(s) catheterization of the ureters? 1. Retrograde urogram 2. Cystogram 3. Voiding cystogram (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

45. (A) Retrograde urograms require catheterization of the urethra and/or the ureter(s). Radiographs that include the kidney(s) and ureter(s) in their entirety are obtained after retrograde filling of the structures. A cystogram or (voiding) cystourethrogram requires only urethral cathe-terization. Radiographs are obtained of the contrast-filled bladder and frequently of the contrast-filled urethra during voiding. Cystoscopy is required for location and catheterization of the vesicoureteral orifices.

46. Some common mild side effects of intravenous administration of water-soluble iodinated contrast agents include 1. flushed feeling 2. bitter taste 3. urticaria (A) 1 only (B) 1 and 2 only (C) 1 and 3 only (D) 1, 2, and 3

46. (B) Because the urinary structures have so little subject contrast, artificial contrast material must be used for better visualization of these structures. Contrast agents used for urographic procedures can have unpleasant, and (rarely) even lethal, side effects. Intravenous injection of contrast frequently produces a warm, flushed feeling, a bitter or metallic taste, or mild nausea. These side effects are of short duration and usually pass as quickly as they come. More serious side effects include urticaria, respiratory discomfort/distress, and, rarely, anaphylaxis. An antihistamine is the appropriate treatment of simple side effects, but the radiographer must always be prepared to deal quickly and efficiently with patients experiencing more serious reactions. Nonionic contrast agents are far less likely to produce side effects.

47. Hysterosalpingograms may be performed for the following reason(s): 1. demonstration of fistulous tracts 2. investigation of infertility 3. demonstration of tubal patency (A) 1 only (B) 1 and 2 only (C) 1 and 3 only (D) 1, 2, and 3

47. (D) The most commonly performed radiologic examination of the reproductive system is hysterosalpingogra-phy, which is used for evaluation of the uterus, oviducts, and ovaries of the female reproductive system. The procedure serves to delineate the position, size, and shape of the structures and demonstrate pathology such as pol-yps, tumors, and fistulas. However, it is most often used to demonstrate patency of the oviducts in cases of infertility and is sometimes therapeutic in terms of opening a blocked oviduct.

49. During routine IVU, the oblique position demonstrates the (A) kidney of the side up parallel to the IR (B) kidney of the side up perpendicular to the IR (C) urinary bladder parallel to the IR (D) urinary bladder perpendicular to the IR

49. (A) During IVU, both oblique positions are generally obtained. The 30° oblique KUB (kidney, ureters, bladder projection places the kidney of the side away from the ×-ray table parallel to the IR. The kidney closer to the x-ray table is placed perpendicular to the IR. The oblique positions provide an oblique projection of the urinary bladder.

5. The following projection(s) should not be performed until a transverse fracture of the patella has been ruled out: 1. AP knee 2. lateral knee 3. axial/tangential patella (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

5. (C) If a transverse fracture of the patella is present and the knee is flexed, there is a danger of separation of the fractured segments. Because both a lateral knee and an axial patella require knee flexion, they should be avoided until a transverse fracture is ruled out. When present, a transverse fracture may be seen through the femur on the AP projection. The axial (sunrise) projection of the patela is generaly used for demonstrating vertical patellar fractures.

50. To better demonstrate contrast-filled distal ureters during IVU, it is helpful to 1. use a 15° AP Trendelenburg position 2. apply compression to the proximal ureters 3. apply compression to the distal ureters (A) 1 only (B) 2 only (C) 1 and 2 only (D) 1 and 3 only

50. (A) A 15°-20° AP Trendelenburg position during IVU is often helpful in demonstrating filling of the distal ureters and the area of the vesicoureteral orifices. In this position, the contrast-filled urinary bladder moves superiorly, encouraging filling of the distal ureters and superior blad-der, and provides better delineation of these areas. The central ray should be directed perpendicular to the IR. Compression of the distal ureters is used to prolong filling of the renal pelvis and calyces. Compression of the proximal ureters is not advocated.

51. The space located between the arachnoid and dura mater is the (A) subarachnoid space (B) subdural space (C) epidural space (D) epiarachnoid space

51. (B) The CNS is enclosed within three tissue mem-branes, the meninges. The pia mater is the innermost vascular membrane, which is closely attached to the brain and the spinal cord. The arachnoid mater is a thin lave outside the pia mater and attached to it by weblike fibers. The subarachnoid space is between the pia and arachnoid mater and is filled with CSf. The brain and spinal cord float in CSF, which acts as a shock absorber. The dura mater is a double-layered fibrous membrane outside the arachnoid mater. The subdural space is located between the arachnoid and dura mater; it does not contain CSF. The epidural space is located between the two layers of the dura mater.

52. During a Gl examination, the lateral recumbent projection of a stomach of average shape will demonstrate 1. anterior and posterior aspects of the stomach 2. medial and lateral aspects of the stomach 3. double-contrast body and antral portions (A) 1 only (B) 1 and 2 only (C) 2 and 3 only (D) 1, 2, and 3

52. (A) Anterior and posterior aspects of the stomach are visualized in the lateral position; medial and lateral aspects of the stomach are visualized in the AP projec-tion. With the body in the AP recumbent position, barium flows easily into the fundus of the stomach, displacing the stomach somewhat superiorly. The fundus, then, is filled with barium, whereas air is displaced into the gastric body, pylorus, and duodenum, demonstrating them as double contrast. Air-contrast delineation of these structures allows us to see through the stomach up to the ret-rogastric areas and structures.

53. The method by which contrast filled vascularimages are removed from superimposition upon bone is called (A) positive masking (B) reversal (C) subtraction (D) registration

53. (C) Superimposition of bony details frequently makes angiographic demonstration of blood vessels less than optimal. The method used to remove these superimposed bony details is called subtraction. Digital subtraction can accomplish this through the use of a computer, but photographic subtraction may also be performed using images from an angiographic series. Registration is the process of matching one series image exactly over another. A reversal image, or positive mask. is a reverse of the black and white radiographic tones.

54. Indicate the correct sequence of oxygenated blood as it returns from the lungs to the heart. (A) Pulmonary veins, left atrium, left ventricle, aortic valve (B) Pulmonary artery, left atrium, left ventricle, aortic valve (C) Pulmonary veins, right atrium, right ventricle, pulmonary semilunar valve (D) Pulmonary artery, right atrium, right ventricle, pulmonary semilunar valve

54. (A) Deoxygenated blood is returned by way of the inferior and superior vena cave to the right side of the heart. The blood is emptied into the right atrium, passes through the tricuspid valve, and enters the right ventri-cle. It is forced through the pulmonary semilunar valve into the pulmonary artery (by contraction of the right ventricle) and passes to the lungs for reoxygenation. From the lungs, it is collected by the pulmonary veins, which carry the oxygenated blood to the left atrium, where it travels through the mitral valve into the left ven-trice. Upon contraction of the left ventricle, blood passes through the aortic valve into the aorta and to all parts of the body.

55. In myelography, the contrast medium is generally injected into the (A) cisterna magna (B) individual intervertebral disks (C) subarachnoid space between the first and second lumbar vertebrae (D) subarachnoid space between the third and fourth lumbar vertebrae

55. (D) Generally, contrast medium is injected into the subarachnoid space between the third and fourth lumbar vertebrae. Because the spinal cord ends at the level of the first or second lumbar vertebra, this is considered to be a relatively safe iniection site. The cisterna magna can be used, but the risk of contrast entering and causing side effects increases.

56. The upper chambers of the heart are the (A) ventricles (B) atria (C) pericardia (D) myocardia

56. (B) The heart wall is made up of the external epicar-dium, the middle myocardium, and the internal endocar-dium. The pericardium is the fibroserous sac enclosing the heart and roots of the great vessels. The heart has four chambers. The two upper chambers are the atria, and the two lower chambers are the ventricles. The apex of the heart is the tip of the left ventricle.

57. Myelography is a diagnostic examination used to demonstrate 1. posterior protrusion of the herniated intervertebral disk 2. anterior protrusion of the herniated intervertebral disk 3. internal disk lesions (A) 1 only (B) 2 only (C) 1 and 2 only (D) 1 and 3 only

57. (A) An intervertebral disk can rupture as a result of trauma or degeneration. The nucleus pulposus protrudes posteriorly through a tear in the annulus fibrous and impinges on nerve roots and can be demonstrated by placing positive or negative contrast media into the subarachnoid space. Internal disk lesions can be demonstrated only by injecting contrast into the individual disks. (This procedure is termed diskography.) Anterior protrusion of a herniated intervertebral disk does not impinge on the spinal cord and is not demonstrated in myelography.

58. The four major arteries supplying the brain include the 1. brachiocephalic artery 2. common carotid arteries 3. vertebral arteries (A) 1 and 2 only (B) 1 and 3 only (C) 2 and 3 only (D) 1, 2, and 3

58. (C) Major branches of the common carotid arteries (internal carotids) function to supply the anterior brain, whereas the posterior brain is supplied by the vertebral arteries (branches of the subclavian arteries). The bra-chiocephalic (innominate) artery is unpaired and is one of three branches of the aortic arch, from which the right common carotid artery is derived. The left common carotid artery comes directly off the aortic arch.

59. Venous, or deoxygenated, blood is returned to the heart via the 1. inferior vena cava 2. superior vena cava 3. coronary sinus (A) 1 only (B) 2 only (C) 1 and 2 only (D) 1, 2, and 3

59. (D) Venous blood is returned to the right atrium of the heart via the superior (from upper body) and inferior (from lower body) venae cavae and the coronary sinus (from the heart substance; see Fig. 7-118). Upon atrial systole, the blood passes through the tricuspid valve into the right ventricle. During ventricular systole, the blood is pumped through the pulmonary semilunar valve into the pulmonary artery and then to the lungs for oxygenation. Blood is returned via the pulmonary veins to the left atrium. During atrial systole, blood passes through the mitral (bicuspid) valve into the left ventricle. During ventricular systole, the oxygenated blood is pumped through the aortic semilunar valve into the aorta.

6. Which of the following best demonstrates the cuboid, sinus tarsi, and tuberosity of the fifth metatarsal? (A) Lateral foot Nitram violibare (betsvaromeb (B) Lateral oblique foot (C) Medial oblique foot (D) Weight-bearing foot

6. (C) To demonstrate many of the tarsals and intertarsa spaces, including the cuboid, third (lateral) cuneror, sinus tarsi, and tuberosity of the fifth metatarsal, a medio, oblique projection is required (plantar surface and IR form a 30° angle). The lateral oblique projection of the foot demonstrates the navicular and first (medial) and second (intermediate) cuneiforms. Weight-bearing lateral feet are used to demonstrate the longitudinal arches.

60. The apex of the heart is formed by the (A) left atrium (B) right atrium (C) left ventricle (D) right ventricle

60. (C) The heart wall is made up of the external epicar-dium, the middle myocardium, and the internal endocar-dium. The pericardium is the fibroserous sac enclosing the heart and roots of the great vessels. The heart has four chambers. The two upper chambers are the atria, and the two lower chambers are the ventricles. The apex of the heart is the tip of the left ventricle.

7. The left SI joint is placed perpendicular to the IR when the patient is placed in a (A) left lateral position (B) 25°-30° RAO position (C) 25°-30° RPO position (D) 30°-40° RPO position

7. (C) SI joints lie obliquely in the pelvis and open anteri-orly at an angle of 25°-30° to the MSP. A 25°-30° oblique position places the joints perpendicular to the IR. The left SI joint is demonstrated in the RPO and LAO positions, with little difference in magnification.

9. An axial projection of the clavicle is often helpful in demonstrating a fracture not visualized using a perpendicular central ray. When examining the clavicle in the AP axial projection, how should the central ray be directed? (A) Cephalad (B) Caudad (C) Medially (D) Laterally

9. (A) With the patient positioned for an AP axial projec-tion, the central ray is directed cephalad. The reverse is true when examining the clavicle in the prone position. This serves to project the pulmonary apices away from the clavicle. Patients having clavicular pain are more comfortably examined using the PA erect or AP recumbent projection/position.