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Mosby’s Exam Review for Computed Tomography 3rd Edition (2019)

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    Mosby's Exam Review for Computed Tomography THIRD EDITION Daniel N. DeMaio, MEd, RT(R)(CT) Chair Department of Health Sciences and Nursing Director Radiologic Technology Program University of Hartford West Hartford, Connecticut 2

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    Table of Contents Cover image Title Page Copyright Dedication Preface Content and Organization Features Acknowledgments Part I Chapter 1 Introduction American Registry of Radiologic Technologists Postprimary Certification in Computed Tomography Nuclear Medicine Technology Certification Board Postprimary Certification in Computed Tomography 4

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    Using This Review Book Text Format Study Habits and Test-Taking Techniques Chapter 2 Review of Patient Care in Computed Tomography Patient Assessment and Preparation Contrast Administration Chapter 3 Review of Safety in Computed Tomography Radiation Safety and Dose Chapter 4 Review of Imaging Procedures in Computed Tomography Head Neck Chest Abdomen and Pelvis Hepatobiliary System Spleen Pancreas Adrenal Glands Genitourinary System Gastrointestinal System Pelvis and Reproductive System Musculoskeletal System 5

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    Chapter 5 Review of Image Production in Computed Tomography CT System Principles, Operation, and Components Image Processing and Display Image Quality Artifact Recognition and Reduction Informatics Part II Chapter 6 Simulated Examination One Questions Chapter 7 Simulated Examination Two Questions Chapter 8 Simulated Examination Three Questions Chapter 9 Answer Key—Examination One Answers Chapter 10 Answer Key—Examination Two Answers Chapter 11 Answer Key—Examination Three Answers 6

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    Glossary Bibliography Index 7

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    Copyright 3251 Riverport Lane St. Louis, Missouri 63043 MOSBY'S EXAM REVIEW FOR COMPUTED TOMOGRAPHY, THIRD EDITION ISBN: 978-0-323-41633-7 Copyright © 2018, Elsevier Inc. All rights reserved. Previous editions Copyright 2011, 1996 by Mosby, Inc., an affiliate of Elsevier Inc No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). 8

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    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 Names: DeMaio, Daniel N., author. Title: Mosby's exam review for computed tomography / Daniel N. DeMaio. Other titles: Exam review for computed tomography Description: Third edition. | St. Louis, Missouri : Elsevier, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2017035969 | ISBN 9780323416337 (paperback) Subjects: | MESH: Tomography, X-Ray Computed | Examination 9

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    Questions Classification: LCC RC78.7.T6 | NLM WN 18.2 | DDC 616.07/57076–dc23 LC record available at https://lccn.loc.gov/2017035969 Senior Content Strategist: Sonya Seigafuse Senior Content Development Manager: Ellen Wurm-Cutter Content Development Specialist: Sarah Vora/ Charlene Ketchum Publishing Services Manager: Deepthi Unni Project Manager: Janish Ashwin Paul Designer: Ryan Cook Printed in United States Last digit is the print number: 9 8 7 6 5 4 3 2 1 10

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    Dedication For my family – Christine, Ryan, and Emily. 11

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    Preface Content and Organization Mosby's Exam Review for Computed Tomography is designed to prepare the radiologic technologist for successful completion of the American Registry of Radiologic Technologists (ARRT) Advanced Certification Examination for Computed Tomography. This review text will also help prepare the nuclear medicine technologist for the Computed Tomography certification examination offered by the Nuclear Medicine Technology Certification Board (NMTCB). Because many general radiographers and nuclear medicine technologists are now cross-training in computed tomography and are performing computed tomography as part of their daily practice, this text will be a valuable resource for preparing for the applicable CT certification examination. This text first offers a thorough review in an outline format of the content areas on the ARRT Computed Tomography Examination: Patient Care, Safety, Image Production, and Procedures. The review is followed by three 165-question mock examinations and answer keys. Features Simulated Examinations The format of the questions is similar to the ARRT examination. Answers and rationales are provided for each question. 12

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    Evolve Resources One of the most valuable features of this review resource is the accompanying Evolve site, http://evolve.elsevier.com/DeMaio/CT . The Evolve site contains questions that can be randomly accessed to compile an unlimited number of variations of mock examinations. Examinations on the Evolve site may be taken in quiz mode with immediate feedback or in a timed mode to simulate the actual examination experience. Daniel N. DeMaio 13

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    Acknowledgments Sincere thanks to the superb staff of Elsevier, including Sonya Seigafuse, Sarah Vora, and Janish Paul. Working with editor Charlene Ketchum was an absolute pleasure, and I am very appreciative of her guidance and support throughout this project. I am truly grateful to Mr. Steven Ahrenstein. Not only did he provide me with some excellent images for this revised edition, but he was also my first CT teacher and helped instill within me a love for this imaging modality that I still carry to this day. To my friends and colleagues at the University of Hartford, thanks for all that you do in support of me, our programs, and our students. I could not ask for a better group of professionals to work with. To my students, past and present, it remains a distinct honor for me to be a part of your education in the radiologic sciences. I have the best job in the world, and so much of that is because of you. To my wife and best friend Christine, our son Ryan, and our daughter Emily, you make me the proudest husband and father on the planet. I love you all more than I'll ever be able to describe with words on a page. Daniel N. DeMaio 14

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    Part I OUTLINE Chapter 1 Introduction Chapter 2 Review of Patient Care in Computed Tomography Chapter 3 Review of Safety in Computed Tomography Chapter 4 Review of Imaging Procedures in Computed Tomography Chapter 5 Review of Image Production in Computed Tomography 15

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    C H A P T E R 1 Introduction CHAPTER OUTLINE AMERICAN REGISTRY OF RADIOLOGIC TECHNOLOGISTS POSTPRIMARY CERTIFICATION IN COMPUTED TOMOGRAPHY NUCLEAR MEDICINE TECHNOLOGY CERTIFICATION BOARD POSTPRIMARY CERTIFICATION IN COMPUTED TOMOGRAPHY USING THIS REVIEW BOOK TEXT FORMAT STUDY HABITS AND TEST-TAKING TECHNIQUES 1. Do Not Wait Until the Last Minute to Prepare! 2. Practice Your Time Management Skills 3. Zero in on the Correct Answer 4. Have Confidence! American Registry of Radiologic Technologists Postprimary Certification in Computed Tomography 16

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    Technologists who wish to enter the postprimary pathway to certification in computed tomography (CT) must hold a registration in one of the following supporting categories: • Radiography • Nuclear Medicine Technology • Radiation Therapy To attain eligibility for American Registry of Radiologic Technologists (ARRT) certification in CT, technologists must complete a minimum of 16 hours of structured education credits in topics that reflect the certification examination content. In addition, candidates for CT certification are required to document performance of core clinical procedures to establish eligibility. Specific educational and clinical requirements and documentation procedures may be obtained from the ARRT. The ARRT postprimary examination in CT was first offered in March 1995. It was designed to give the technologist an opportunity to become certified in the specific modality of CT. The CT registry is a 165-question, multiple-choice examination covering four major subject areas in the following manner: • Patient Care: 22 questions • Safety: 20 questions • Image Production: 55 questions • Procedures: 68 questions The latest content specifications for the ARRT examination in CT are provided in the box at the end of this chapter. The approximate number of test questions for each major topic is provided in parentheses. The computer-based CT certification examination is currently given at specific test centers located throughout the United States. Please contact the ARRT (www.ARRT.org) for additional information regarding application procedures, deadlines, testing center locations, and so on. Nuclear Medicine Technology Certification Board Postprimary 17

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    Certification in Computed Tomography Nuclear medicine technologists certified by the Nuclear Medicine Technology Certification Board (NMTCB), the Canadian Association of Medical Radiation Technologists (CAMRT), or the ARRT may be eligible to sit for the new CT certification examination offered by the NMTCB. First offered in 2014, this 200- question multiple-choice examination covers much of the information included on the ARRT certification examination in CT. However, the NMTCB/CT certification examination also includes information pertaining to the hybrid imaging studies that combine CT with molecular imaging techniques such as positron emission tomography (PET) and single-photon emission computed tomography (SPECT). To attain eligibility for NMTCB certification in CT, technologists must complete a minimum of 35 contact hours of instruction in the following topics: • Contrast administration • Cross-sectional anatomy • X-ray physics • CT radiation safety In addition, appropriately credentialed nuclear medicine technologists must complete a minimum of 500 clinical hours in CT, PET/CT, and/or SPECT/CT. Specific educational and clinical requirements and documentation procedures/forms may be obtained from the NMTCB. Using This Review Book The first edition of this book, titled Registry Review in Computed Tomography, was developed shortly after I had successfully completed the CT registry examination in March 1995. A second edition published in 2011 was vastly updated and expanded. This third edition incorporates much of the information included in the second edition, but has been completely revised and updated to 18

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    include the latest information on this dynamic imaging modality. This review text is essentially designed for two different groups of examination applicants. For the established CT technologist, the review outline and examination questions help bridge the gap between clinical experience and cognitive knowledge. Those of you who are experienced in CT will already be familiar with much of the subject matter covered. This review book allows you to answer questions concerning the principles and procedures that you put into practice each day. Used in conjunction with some additional reference materials, this book should adequately prepare you for the CT certification examination. Keep in mind that the ARRT and NMTCB CT certification examinations are “advanced-level” examinations. Some of the subject matter may go beyond the standard responsibilities of the staff CT technologist. Practical experience in CT does not eliminate the need for study and preparation in order to achieve success on this examination. Many examinees may be looking to use an advanced-level certification examination as a vehicle toward developing a career in CT. This second group of test applicants may have little experience in CT beyond the ARRT or NMTCB clinical requirements. If you are among this group, you have a significantly larger amount of work ahead of you. It would certainly be advisable to use several of the textbooks listed as references in the bibliography during the initial stages of preparation. It is extremely important to review the physical principles of CT imaging along with the many clinical applications, such as patient care, scanning protocols, cross- sectional anatomy, and the identification of pathology on the CT image. Mosby's Exam Review for Computed Tomography will then serve as an invaluable tool to test your newly acquired knowledge and practice “registry-type” questions. Please remember that the best way to reap benefits from review books such as this one is to concentrate on the material you are unfamiliar with: the questions that you incorrectly answer. It is not sufficient to simply grade each examination and calculate your score to determine whether or not you passed the examination. Take the time to carefully review each chapter. If you find that you are in need of further explanation, turn to the bibliography for 19

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    additional study materials. Attempt the practice examinations with the mind-set that they are “dry runs” for the real thing. After grading a practice examination, concentrate on the questions that you answered incorrectly. Look up each correct answer, read the brief explanation given, and then further review the topic in the review chapter and/or bibliography provided. You have much more to learn from the mistakes that you make, and when properly used, this book will give you the information you need. Text Format Part I of Mosby's Exam Review for Computed Tomography contains a review in outline form of the four content areas covered on the ARRT certification examination in CT. In addition, information specific to the NMTCB certification examination in CT is included in the outline. Part II contains three examinations and the answers for each examination. A brief explanation accompanies each correct answer, and more detailed information about the question's subject may be found in the review chapters. Many of the questions in each examination pertain to an included CT image. Be sure to use all of the information provided by the image when attempting to correctly answer these questions. Each examination contains 165 multiple-choice questions. The topics for questions follow the latest content specifications of the ARRT and NMTCB advanced-level examination in CT. Each practice examination is weighted by subject area in a similar manner to the ARRT certification examination.” Study Habits and Test-Taking Techniques Each of you preparing to take an advanced-level certification examination in CT is a registered and/or licensed medical imaging technologist. Most of you have already successfully completed a similar certification examination in an imaging discipline. You undoubtedly know how to take standardized examinations, and 20

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    your previous results support this assumption. However, it may have been some time since you participated in a standardized examination, so here are some points to assist you in your preparation. 1 Do Not Wait Until the Last Minute to Prepare! Although easier said than done, beginning to study early definitely improves your potential for success. The review chapters are just that—a review! They provide succinct outlines of the pertinent material and will serve as an excellent resource. But you may also find yourself in need of additional, more in-depth information. There is a multitude of excellent resources in both print and online form. Start with a general text in the physical principles of CT and progress through the many clinical applications. Also, a large proportion of the examination pertains to cross-sectional anatomy. Do not rely only on your practical experience in this area. Take care to review the CT images in this text. You may want to refer to the cross-sectional anatomy books listed in the bibliography for additional review. For some people, this book may be sufficient as the sole preparatory tool for the CT examination. However, it is not a “quick fix” and will not make up for lack of adequate experience, research, and study. 2 Practice Your Time Management Skills Time management is equally important during preparation and while you are taking the actual examination. The ARRT allows you 3.5 hours to complete 165 questions. This should be more than sufficient if you take care to keep track of your progress during the examination. You will be provided with a countdown timer during the computerized examination and should follow the standard rule of not spending too much time on any one question. 3 Zero In on the Correct Answer Success on standardized examinations relies on your ability not 21

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    only to choose the correct answer, but also to identify the incorrect ones. The process of elimination is your most valued asset when you encounter a multiple-choice question. Carefully examine each answer, and eliminate those that are obviously incorrect. This step often narrows the possible choices and improves your chances when guessing becomes a necessity. 4 Have Confidence! You are in the midst of a successful career in medical imaging. Your interest in the field and your dedication to continued learning have brought you here to this advanced-level examination. Have confidence in your ability, and put some faith in your preparation and experience: you know the material, so relax, and simply tap into this knowledge. American Registry of Radiologic Technologists Computed Tomography Certification Examination: Content Specifications Patient Care (22) 1. Patient interactions and management (22) A. Patient assessment and preparation 1. Clinical history 2. Scheduling and screening 3. Education 4. Consent 5. Immobilization 6. Monitoring 22

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    a. Level of consciousness b. Vital signs c. Heart rhythm and cardiac cycle d. Oximetry 7. Management of accessory medical devices a. Oxygen delivery systems b. Chest tubes c. In-dwelling catheters 8. Lab values a. Renal function (e.g., BUN, eGFR, creatinine) b. Other (e.g., D -dimer, LFT, INR) 9. Medications and dosage a. Current b. Preprocedure medications (e.g., steroid, antianxiety) c. Postprocedure instructions (e.g., diabetic patient) B. Contrast administration 1. Contrast media a. Ionic, nonionic b. Osmolarity c. Barium sulfate d. Water soluble (iodinated) 23

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    e. Air f. Water g. Other 2. Special contrast considerations a. Contraindications b. Indications c. Pregnancy d. Lactation e. Dialysis patients 3. Administration route and dose calculations a. IV b. Oral c. Rectal d. Intrathecal e. Catheters (e.g., peripheral line, central line, PICC line) f. Other (e.g., stoma, intraarticular) 4. Venipuncture a. Site selection b. Aseptic and sterile technique c. Documentation (e.g., site, amount, gauge, concentration, rate, and number of attempts) 5. Injection techniques 24

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    a. Safety b. Manual c. Power injector options 1. Single or dual head 2. Single phase 3. Multiphase 4. Flow rate 5. Timing bolus 6. Bolus tracking 6. Postprocedure care a. Treatment of contrast extravasation b. Documentation 7. Adverse reactions a. Recognition and assessment b. Treatment c. Documentation Safety (20) 1. Radiation safety and dose A. Radiation physics 1. Radiation interaction with matter 2. Acquisition (geometry) 25

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    3. Physical principles (attenuation) B. Radiation protection 1. Minimizing patient exposure a. kVp b. mAs c. Pitch d. Collimation/beam width e. Multidetector configuration f. Gating 2. Personnel protection a. Controlled access b. Education 3. Shielding a. Traditional (e.g., lead apron) b. Nontraditional (e.g., bismuth) 4. Dose measurement a. CT dose index (CTDI) b. Dose length product (DLP) c. Documentation 5. Patient dose reduction and optimization a. Pediatric 26

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    b. Adult c. Dose modulation techniques (e.g., SMART mA, auto mA, CARE dose, and SURE exposure) d. Iterative reconstruction e. Dose notification f. Dose alert Image Production (55) 1. Image formation (30) A. CT system principles, operation, and components 1. Tube a. X-ray production b. Warm-up procedures 2. Collimation/beam width 3. Generator 4. Detectors a. Detector configuration b. Detector collimation 5. Data acquisition system (DAS) 6. Computer and array processor B. Imaging parameters and data acquisition 1. Parameters 27

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    a. kVp b. mAs c. Pitch d. Acquisition thickness e. x, y, z planes f. Scan field of view 2. Acquisition a. Axial/sequential b. Helical/spiral c. Volumetric C. Image processing 1. Reconstruction a. Filtered back projection reconstruction b. Iterative reconstruction c. Interpolation d. Reconstruction algorithm e. Raw data vs. image data f. Prospective/retrospective reconstruction g. Reconstruction thickness h. Reconstruction interval 2. Postprocessing 28

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    a. Multi-planar reformation (MPR) b. 3-D rendering (MIP, SSD, VR) c. Quantitative analysis (e.g., distance, diameter, calcium scoring, ejection fraction) 2. Image evaluation and archiving (25) A. Image display 1. Pixel, voxel 2. Matrix 3. Image magnification 4. Display field of view (DFOV) 5. Window level, window width 6. Cine 7. Geometric distance or region of interest (ROI) (e.g., mean, standard deviation [SD]) B. Image quality 1. Spatial resolution 2. Contrast resolution 3. Temporal resolution 4. Noise and uniformity 5. Quality assurance and accreditation 6. CT number (Hounsfield units) 7. Linearity 29

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    C. Artifact recognition and reduction 1. Beam hardening or cupping 2. Partial volume averaging 3. Motion 4. Metallic 5. Edge gradient 6. Patient positioning (out-of-field) 7. Equipment induced a. Rings b. Streaks c. Tube arcing d. Cone beam e. Capping D. Informatics 1. Hard/electronic copy (e.g., DICOM file format) 2. Archive 3. PACS and electronic medical record (EMR) 4. Security and confidentiality 5. Networking Procedures (68) 30

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