BRPT

Question 1

Prior to each nap opportunity of a clinical MSLT, the technologist should instruct the patient to lie quietly:

Answer 1

With eyes closed, and to try not to resist falling asleep.
JUSTIFICATION:
Identification of sleep onset latency is a principal outcome of a clinical MSLT nap. Instructing the patient to lie quietly and not resist falling asleep is important to achieving that outcome. Failure to give clear instructions can result in fear, frustration, and decreased cooperation from the patient and can negatively affect results of the test. Instructing the patient to remain awake is a completely wrong answer; this type of direction would be given to a patient having a MWT.

Question 2

When MSLT nap procedures are explained to a patient, all of the following are appropriate EXCEPT that the patient:

Answer 2

Can call to use the rest room during testing.
JUSTIFICATION:
Instructions given to a patient before a MSLT should include using the restroom prior to starting each nap session so that latencies and test results are not affected by such interruptions. A patient should also be instructed to dress in street clothes as well as being told that they can move freely in bed during the naps. Patients should also be told not to worry if they are unable to fall asleep.

Question 3

If a calibration signal on an EEG recoding channel decays to baseline faster than expected during montage calibrations, the:

Answer 3

LFF is set to high.
JUSTIFICATION:
The rate at which a calibration signal decays back to baseline is a function of the LFF setting. The higher the number on the setting, the faster the signal will decay. The lower the number on the setting, the slower the signal will decay. If the decay rate is too fast, that means that the setting is too high. The HFF does not affect the rate at which the calibration signal decays.

Question 4

Which of the following describes the EEG waveform at point X?

Answer 4

Sawtooth Wave.
JUSTIFICATION:
This graphic demonstrates REM sleep. Sawtooth waves are seen in REM sleep as 2-3 Hz sharply contoured triangular waves, usually occurring serially, best seen in the central leads. Vertex sharp waves are also seen in the central leads, but occur during sleep stages 1 and 2. K-complexes are well-delineated negative sharp waves followed by a positive component that exceeds 0.5 seconds duration and seen in sleep stages 2,3 and4. Epileptiform activity is usually less evident during REM sleep, and takes on a different appearance.

Question 5

The most important factor to consider when storing acetone is the:

Answer 5

Temperature of the storage area.
JUSTIFICATION:
Because acetone is highly flammable, it should be stored in an area that is not exposed to excessive heat, spark, or open flame. As long as the acetone is stored in an acceptable container and is away from heat, spark, or flame, the surrounding free space is irrelevant. An explosion proof ventilated closet is the best place to store acetone. The size of the container has no bearing on the storage of acetone. The MSDS incites the amount of ventilation that should be maintained during the use of acetone.

Question 6

After a PSG with esophageal pressure monitoring a fluid-filled catheter, what should the technologist do with the catheter?

Answer 6

Dispose in a biohazard container.
JUSTIFICATION:
The esophageal pressure monitoring catheter is intended for single patient use and should be discarded following Universal Precautions. Steam autoclaving requires 15 minutes at 121-127 degrees at 15 psi, which would melt the catheter and render it unusable. Glutaraldehyde and bleach are considered caustic agents and can interfere with the integrity of the catheter.

Question 7

In an 80-year-old patient with an Erythematous uvula, the PSG shows repetitive episodes of progressively lengthening R-R interval occasionally exceeding 5 seconds in duration. These findings are most likely associated with:

Answer 7

Apnea episodes.
JUSTIFICATION:
A re irritated uvula is often related to the occurrence of obstructive apnea. The ECG phenomena described is episodic bradycardia, which is also often associated with obstructive apnea. Seizures can be associated with tachycardia or bradycardia, but this seems to be a less likely association in this case, Cataplexy and transient arousals would not likely be associated with significant bradycardia.

Question 8

The IDEAL electrode impedance range for EEG electrodes would be:

Answer 8

1000-5000 ohms
JUSTIFICATION:
The best impedance range for electrodes used for biopotential recording (EEG, EMG, etc.) is 1000-5000 Ohms. Impedances lower than 1000 ohms can sometimes result in decreased amplitude. Impedances higher than 5000 ohms can result in excessive artifact, including 60-cycle interference. Impedance levels outside the desirable range of 1000-5000 ohms might indicate inadequate skin preparation or electrode attachment resulting in compromised signal quality.

Question 9

Extraneous high-frequency artifacts in a PSG may be caused by all of the following EXCEPT:

Answer 9

A haring aid.
JUSTIFICATION:
There are many sources of environmental signals that can be recorded in all testing environments. However, hearing aides are DC battery operated and are not connected to any power source that might create electrical interference. One of the main sources for high frequency artifact is 60 Hz. from environmental interference. Electrical beds and fluorescent lights are connected to a power source and can create 60-cycle interference with the recording when making and receiving calls. At times, the cell phone can create interference in the recording by just being in the “on” position.

Question 10

At a time base of 10 mm/sec, a sleep spindle must have a minimum width of ____ millimeters.

Answer 10

5.0
JUSTIFICATION:
The minimum duration criterion for a sleep spindle is .5 second (half of one second). At a timebase of 10 mm/sec (10 mm of data per second), a half of one second would result in half of 10 mm, which is 5 mm. Therefore, a .5-second duration equals a 5 mm width when using a 10 mm/sec time base.

Question 11

A periodic abnormal ECG conduction that occurs after every two normal beats is referred to as:

Answer 11

Trigeminy.
JUSTIFICATION:
Trigeminy refers to two normal sinus beats for every one premature beat. If the ratio is one normal sinus beat to one premature beat, the rhythm is bigeminy. Second degree A-V Block, also called Wenckebach is the progressive lengthening of the P-R interval until one P-wave fails to conduct and is not followed by a QRS complex. Third degree A-V block, also called A-V dissociation, is demonstrated by a ventricular rate that is slower than the atrial rate.

Question 12

All of the following procedures are required for proper physiologic calibration during a routine polysomnogram EXCEPT:

Answer 12

Hyperventilating.
JUSTIFICATION:
Opening and closing a patient’s eyes, flexing of limbs, and grinding teeth are all useful for documenting electrode/sensor integrity, as well as polygraphically documenting patient specific physiological waveforms and patterns that will be useful to the technologist during recording and analysis. Hyperventilation is a technique used during clinical EEG testing for activation of seizures, but does not provide any useful information relevant to polysomnography.

Question 13

A patient arrives for the sleep study on 3.0 L/min of oxygen. The physician’s orders specify to begin the study without supplemental oxygen, but to add oxygen at 1 L/min if the SpO2 is less than 89%. The technologist should:

Answer 13

Notify the physician of the 3.0 L/min upon arrival.
JUSTIFICATION:
It is important to assure that the patient maintains adequate SpO2. It cannot be assumed that the physician writing the orders for the study is aware that the patient is currently using 3 L/min of O2. Allowing for a low SpO2 include increases in cardiac dysrhythmia, elevated daytime arterial pressure, and poor objective and subjective sleep quality measures. The physician might have a valid reason for starting the study without O2, but this needs to be clarified. Assurance that the study is being performed axxording to physician expectations will help assure that the resulting data provides the answers the physician needs for appropriate patient care. Starting at 1 L/min does not follow instructions or leave the patient at a level that has apparently been determined to be necessary.

Question 14

The apnea/hypopnea index is reported as which of the following:

Answer 14

The average number of apneas and hypopneas seen per hour of sleep.
JUSTIFICATION:
The apnea-hypopnea index is derived from a specific formula which is the sum total of apneas and hypopneas during sleep divided by the total sleep time. The apnea-hypopnea index represents the sum total of apneas and hypopneas per hour of sleep. For example: A patient has 64 hypopneas and 86 apneas that occur during 7.5 hours of sleep.

Question 15

An MSLT is to be performed after an 8-hour PSG test. The patient’s PSG results reveal a sleep efficiency of 50%. The patient claims to usually sleep for 6 hours per night at home. The technologist should:

Answer 15

Contact the physician for further instructions.
JUSTIFICATION:
If the quality of a patient’s sleep is significantly disrupted, or the quantity is significantly decreased, MSLT results can be altered. The Physician should make the decision regarding whether to proceed with the MSLT, or to reschedule the patient at another time, utilizing a two-week diary prior to the procedure. Discounting patient data and allowing the patient extra sleep are incorrect actions and could lead to altered or invalid test results.

Question 16

While scoring a PSG study, a technologist notes a 30-second apneic event accompanied by a 3-second burst of four abnormally wide QRS complexes on the EKG channel. What action should be taken by the scoring technologist?

Answer 16

Provide documentation on the record and in the report.
JUSTIFICATION:
Three or more consecutive abnormally wide QRS complexes are indicative of ventricular tachycardia. Because ventricular tachycardia often leads to ventricular fibrillation (a life-threatening dysrhythmia) the physician should be made aware of its occurrence. It is the technologist’s responsibility to clearly document any events that occur during the recording. Disregarding this rhythm would be incorrect because ventricular tachycardia can degenerate into ventricular fibrillation, which can result in death. Ordering diagnostic procedures and discussing test results or advising patient is beyond the scope of practice of a PSG technologist.

Question 17

A Wenckebach dysrhythnia is associated with:

Answer 17

A block within the AV node.
JUSTIFICATION:
Wenkebach AV block can accur in normal subjects during sleep and are believed to be secondary to the effects of increased parasympathetic activity on the AV node condition during sleep. A block within the SA node is characterized by the sinus node firing normally but the depolarization wave is immediately blocked from transmission into atrial tissue. On the ECG, it appears as a pause in the normal cardiac cycle. The septal fascicle is one of three fascicles that make up the left bundle branch. The Purkinje fibers are a component of AV node, however, dysfunctional Purkinje fibers would not cause Wenkebach.

Question 18

Which of these symptoms is most commonly associated with narcolepsy?

Answer 18

Cataplexy.
JUSTIFICATION:
Of the choices given, cataplexy is most commonly associated with narcolepsy. Two essential features of narcolepsy are sudden, irresistible sleep attacks and cataplexy. Cataplexy is characterized by sudden loss of muscle tone with maintained consciousness. Bruxism, or tooth grinding, during sleep is not associated with narcolepsy. Although narcoleptics might demostrate an increased amount of stage one sleep, frequent awakenings, and disruption of normal sleep patterns, complaints of insomnia are not common. Nocturia (urinary frequency) during sleep is not associated with narcolepsy.

Question 19

Sleep initiation in newborns usually begins with:

Answer 19

Active sleep.
JUSTIFICATION:
The five states for behavioral sleep in newborns include drowse or daze, active, active-quiet transition, quiet and sleep-wake transition. Although sleep states in infants can be disrupted by stress, it is typical for a newborn (up to 6 months) to demonstrate active sleep as the onset sleep. In an older child or adult, quiet sleep becomes the onset sleep. Indeterminate sleep is a term used for transitional sleep that can include both active-quiet transition and sleep-wake transition.

Question 20

Which of the following is TRUE regarding CPAP therapy in children?

Answer 20

It should include parent education, desensitization, and modeling.
JUSTIFICATION:
PAP therapy might be indicated and can be used successfully by all ages of children, including infants. However, it is important that the initial approach to the family and child be carried out correctly and successfully by practitioners experienced in the techniques of desensitization, parent training, and modeling. Children on PAP therapy should be followed regularly to ensure compliance and proper fit as he or she grows. Adenotonsillectomy is the treatment of choice for children with sleep disordered breathing and enlarged tonsils and adenoids.

Question 21

If a patient asks a technologist for information regarding a possible sleep apnea diagnosis, it would be most appropriate to:

Answer 21

Provide them with a pamphlet about sleep apnea.
JUSTIFICATION:
It is appropriate for a technologist to provide general written information, such as educational pamphlets about sleep apnea, and to encourage their patient to discsuss his/her diagnosis with their physician. although it is appropriate and desirable to develop good patient rapport with their patient, it is not appropriate for the technologies to make a treatment recommendation or to discuss the specifics of a patient’s diagnosis. BRPT standards of conduct specifically prohibit a technologist from taking primary responsibility for the interpretation of the polysomnogram.

Question 22

For scoring purposes, the recording of an all-night polysomnogram officially begins with:

Answer 22

Lights off.
JUSTIFICATION:
Scoring is done between lights off and lights on. Physiologic calibrations are recorded prior to the beginning of the procedure to ensure that the electrodes and monitors are functioning properly. Sleep onset is defined as the time from lights off the three consecutive epochs of stage one sleep or one epoch of any other stage of sleep. Electrode application is one of the first things that occurs in a laboratory setting prior to connecting the patient to the polygraph.

Question 23

Which of the following methods would BEST help distinguish idiopathic CSA from Cheyne-Strokes CSA?

Answer 23

Observe for a crescendo-decrescendo sequence in the effort channels.
JUSTIFICATION:
As opposed to CSA, Cheyne-Strokes breathing is a special kind of central apnea manifested as cyclic changes in breathing with crescendo- decresendo sequence separated by central apneas. CSA does not include a crescendo-decresendo pattern, and is practically identical to obstructive sleep apnea, with the exception of the absence of respiratory effort during the event. The presence of snoring and respiratory effort would be indicative of apnea events of obstructive origin. Esophageal pH data would be irrelevant in making the determination between Cheyne Strokes and CSA.

Question 24

Which of the following substances may reduce the effectiveness of PAP therapy?

Answer 24

Alcoholic beverges.
JUSTIFICATION:
Alcohol has an inhibitory effect on upper airway muscle activity. Alcohol also impairs the arousal response to airway occlusion, and a patient’s apneas tend to be longer and also associated with more sever desaturations. Some have hypothesized that alcoholic beverages might reduce the effectiveness of an optimal level of nasal PAP therapy. In patients that are prone to nasal congestion, decongestant nasal sprays can actually be of some benefit to their tolerance of PAP therapy.

Question 25

A patient with a history of abnormal sleep-related behavior that usually occurs between 3 a.m. and 6 a.m. has an episode during the PSG. Which of the following would be appropriate to assess after the event?

Answer 25

Dream recall, Level of consciousness, Injury to the patient.
JUSTIFICATION:
The correct answer is C because the behavior could be arising from any stage of sleep. Dream recall can be correlated to the event in REM behavior disorder. Level of consciousness should be assessed to help differentiate REM from NREM or epileptic events. It is appropriate to assess injury following any significant behavior. Patients with REM sleep behavior disorder will usually have dream recall following an event, and knowledge and documentation of this can be important for the physician when trying to make a diagnosis. The subjective sleep latency would not be appropriate to assess in this situation.

Question 26

The PRIMARY function of EPAP is to:

Answer 26

Prevent the upper airway from being occluded.
JUSTIFICATION:
The point within the inspiratory/expiratory cycle at which the airway becomes obstructed in patients with obstructive sleep apnea is the end of the expiratory phase. An effective EPAP pressure setting provides a sufficient pressure to prevent airway obstruction during the patent’s expiratory phase. Although sufficient EPAP pressure will likely result in elimination of respiratory events, it can also result in decreased arousals for the patient. It can also sometimes result in better saturations. Although decreased arousals and better saturation levels are both favorable outcomes, they are not the primary reason for EPAP. PAP delivered during the patient’s inspiratory phase does not prevent airway obstruction.

Question 27

The MOST commonly seen response from initiation of PAP in patients with severe sleep-disordered breathing is:

Answer 27

A rebound of slow wave and REM sleep.
JUSTIFICATION:
REM and slow wave sleep rebound are the lengthening and/or duration of stages 3, 4 and REM sleep. When the correct PAP levels is reached and the patient’s airway is patent, sleep fragmentation decreases. Slow wave and REM sleep rebound might occur because the sleep depriving influence has been removed. Though hypoxemia is sometimes seen with PAP initiation, it improves once the obstruction is corrected. Alpha is typically a waking EEG pattern that attenuates, when the patient’s eyes are open. Restless legs syndrome occurs while the patient is awake. Though restless leg activity might increase once sleepiness is resolved by treatment, this would not commonly be seen as an initial response.

Question 28

An EKG artifact occurs in the C3-A2 recording channel. Which of the following is the BEST intervention to attenuate/eliminate this artifact?

Answer 28

Use combined A1-A2 reference.
JUSTIFICATION:
ECG artifact in the EEG and/or EOG channels can be minimized or eliminated by linking the two reference electrodes (A1 and A2). However, when using this type of montage it is important for the technologist to be aware of the fact that if either of the reference electrodes is contaminated with any other type of interference, the connection between the two references will contaminate all of the EEG and EOG channels. Changing the high and low filters will not eliminate ECG artifact. Because the C3 placement is not located close to a pulse point and a “bad” electrode does not cause ECG artifact, reapplying the electrode would not likely affect the artifact.

Question 29

MSLT sleep latencies:
Nap 1: 1.5 minutes (NOREM)
Nap 2: 5.0 minutes (NOREM)
Nap 3: 3.5 minutes (NOREM)
Nap 4: 4.0 minutes (NOREM)
Nap 5: Not tested 
Based on the information above, it can be concluded that the mean sleep latency for this patient:

Answer 29

Represents pathological sleepiness.
A mean sleep latency is the average of the latencies of the naps. In this case, latencies of 1.5+5+3.5+4.0=14 minutes. This is then divided by 4 (number of naps performed). The mean sleep latency in this patient is 4.6 minutes. A mean sleep latency of 5 minutes or less suggests pathological sleepiness. A score of more that 5 minutes but fewer than 10 minutes is considered a diagnostically gray area, and a score of more than 10 minutes is considered to be in the normal range.

Question 30

During a clinical MSLT nap with 30-second epochs, the following events occur:
lights out on epoch 1, sleep onset at epoch 20, and REM onset at epoch 30. The nap should be ended at the end of epoch____

Answer 30

50.
JUSTIFICATION:
MSLT Guidelines state that a nap opportunity should be terminated 15 minutes after sleep onset, which is 30 epochs, or after 20 minutes (40 epochs) if the patient does not fall asleep. In this case, sleep onset was at epoch 20, so the nap would be terminated at epoch 50(20+30=50).

Question 31

Epileptiform acticity is LEAST likely to occur during:

Answer 31

REM sleep.
JUSTIFICATION:
There is often a reduction or actual disappearance of epileptiform activity during REM sleep. Studies have shown that focal epileptiform discharges increase during stages 1 and 2, whereas generalized epileptiform discharges increase during stages 3 and 4. The period of transition from wakefulness to sleep is the period during which epileptiform activity is most likely to occur.

Question 32

Which of the following conditions is MOST likely to occur due to an improperly fitting CPAP mask?

Answer 32

Conjuctivitis - EYE
JUSTIFICATION:
Conjunctivitis can be a result of air leak from an improperly fitted PAP mask, and is one of the most common complications. Uvular hypertrophy and cold sores do not occur as a result of an improperly fitted mask. Temporomandibular joint pain can occur as a result of the use of mandibular repositioning devices, bur is not related to, or a complication from an improperly fitted mask.

Question 33

PSG is ordered as a split-night titration. Which of the following would be an indication to initiate PAP therapy?

Answer 33

Apnea hypopnea index >30
JUSTIFICATION:
Usually an apnea/hypopnea index of 5 or more is considered an abnormal number of sleep respiratory disturbances, therefore an apnea hypopnea index of 30 is considered to be well within treatment range for OSA. An apnea-hypopnea index of <5 is considered normal. Periodic and habitual snoring are not indications for pap titration in a split night protocol.

Question 34

The presence of electrical interference can MOST EASILY be determined by:

Answer 34

Increasing the time base to 60mm/sec and counting the exact frequency.
JUSTIFICATION:
To appropriately recognize the presence of 60Hz. Interference, it might be necessary to increase your display speed to a 1-second epoch (60 mm per second). The waveform will alternate 60 time within that one second and can easily be counted. Although this can be done with a time base of 30 mm/sec, it will be more easily accomplished at 60 mm/sec. When the presence of 60Hz. is identified, the technologist should then determine the source of the artifact and attempt to eliminate it.

Question 35

Which of the following would be MOST LIKELY to precipitate a cataplectic attack?

Answer 35

Emotional response.
JUSTIFICATION:
Cataplexy can be elicited by emotional responses, most commonly laughter or anger. Tricyclics can result in a rebound effect. Benzodiazepines, however, have no effect on cataplexy. Cataplexy is not related to respiratory physiology. Although hyperventilation can be used for clinical activation of certain types of seizures, it does not elicit cataplexy.

Question 36

During physiologic calibrations, a patient is instructed to breath through her mouth and nose, and then hold her breath. Which of the following is the MOST important reason to perform these maneuvers?

Answer 36

Assess function of respiratory devices.
JUSTIFICATION:
These maneuvers allow the technologist to assess and document the integrity of the respiratory monitoring devices. Having the patient breath through her mouth and nose separately documents that the sensors are positioned and functioning correctly. Having the patient hold her breath simulates and apnea event and allows the technologist the opportunity to adjust the sensor or amplifier settings if necessary. Tidal volume is the amount of gas moving in and out of the respiratory tract and though it can be measured during inspiration or expiration, is not a part of physiological calibrations in polysomnography. Actual amplifier calibrations are a DC calibration and are performed prior to connecting the patient to the polygraph. The instructions given will not assess maximal effort, and there is no need to do so in routine polysomnography.

Question 37

A 4-year-old child with behavioral problems arrives at the sleep lab with her mother for a PSG. To adequately prepare for this study, the technologist should:

Answer 37

Allow the parent to sleep in a bed provided for them in the child’s room.
JUSTIFICATION:
The young patient’s sense of security is reinforced by the presence of a parent. A bed should be provided for the parent because the patient should always sleep in a separate bed. Behavior and movement of a parent sleeping in the same bed as the child could interfere with accuracy of the data being recorded. The parent should remain throughout the night to provide comfort for the child should they awaken in the night. Patients and individuals who accompany them should not be routinely allowed in the control room.

Question 38

When storing digitized polysomnograms, the number of studies that can be stored is mostly dependent upon:

Answer 38

Sampling rate.
JUSTIFICATION:
The number of samples stored in a given amount of time directly determines the amount of storage space that is required. A PSG recorded at a sampling rate of 300 samples per second will require twice the storage spaces as it would if it had been recorded at 150 samples per second. Filter settings, sensitivity settings and epoch size do not have any impact on the amount of space required to store digital media.

Question 39

The BEST action when encountering potentially infectious material from a patient is to:

Answer 39

Remove and dispose of the material according to institutional policies and procedures.
JUSTIFICATION:
Medical waste requires careful disposal and collection. These measures are designed to protect the workers who generate the waste and the workers who manage the waste from the point of generation to disposal. Technologists should be familiar with their institution’s policies and procedures for infection control, which could include notifying the lab manager and the infection control committee following disposal of the waste.

Question 40

During polysomnography testing a short REM latency can be an indication of narcolepsy. What else could explain a short REM latency?

Answer 40

Patient sleeping prior to beginning the test.
JUSTIFICATION:
A normal REM latency in adults is within a 60-90 minute range following sleep onset. If a patient is allowed to doze or sleep prior to beginning a polysomnogram, the non-REM sleep activity that normally occurs prior to REM onset would not be recorded, resulting in a false-positive short REM latency. It is critical to observe and monitor patients prior to beginning the test. Antidepressant medication will often increase REM latency would more likely be increased, not decreased. Withdrawal from REM suppressing medications or drugs, including alcohol, can shorten a patient’s REM latency, but alcohol consumption would likely cause a longer REM latency.

Question 41

For a patient with a distance of 36 cm between their pre-auricular points, what is the distance between the correct site of Cz and C3?

Answer 41

7.2 cm
JUESTIFICATION:
The primary transverse measurement used in the International 10-20 Electrode Placement system is between the pre-auricular points. Cz is located at the midpoint of this distance, or 18cm. The distance between any two adjacent electrodes along this line is 20% of the total distance, or 20% of 36cm, which is 7.2cm. Therefore, the distance between Cz and C3 would be 7.2cm.

Question 42

When only one channel of respiratory effort is recorded in addition to airflow, it is not possible to distinguish normal breathing patterns from:

Answer 42

Paradoxical breathing.
JUSTIFICATION:
Paradoxical breathing is a pattern that can result from a patient struggling to breath against a closed airway. Because the airway is closed, as the patient attempts to inhale by using chest wall musculature, the abdomen contracts instead of expanding concurrently as it would during breathing with an open airway. This out-of-phase movement can only be detected with separate recordings of abdominal and thoracic effort. Both obstructive and central hypopnea are characterized by decreased flow in the presence of some effort. One respiratory effort recording channel is sufficient to measure obstructive and central hypopnea. Hypoventilation (a persistent decrease in respiratory effort) can also be detected by using only one respiratory effort channel.

Question 43

Why are AC amplifiers used to record EEG and EMG activity?

Answer 43

DC components may develop a higher amplitude than the AC potentials of interest.
Low-frequency potentials not of interest can be filtered out with an AC amplifier.
JUSTIFICATION:
DC components and low frequency potentials including common artifacts can interfere with the ability to visualize the electrical activity of interest. EEG and EMG signals occur within a relatively narrow bandwidth and AC amplifiers allow the signals outside this bandwidth to be partially or completely eliminated. Option 3 is incorrect because AC amplifiers have differential inputs that allow the comparison of two inputs that are commonly referred to as grid 1 and grid 2. Only DC amplifiers have non-differential inputs.

Question 44

Minimal requirements for oxygen administration should include which of the following?

Answer 44

Physician's order
Flow rate
Administration device.
JUSTIFICATION:
A physicians order, a flow rate, and a device to administer the oxygen is a drug and cannot be administered without a doctor's order. The oxygen flow rate is crucial to efficacy, and a device such as a nasal cannula is necessary to get the oxygen to the patient. Arterial blood gasses are useful in assessment of patients with compromised lungs function, but are not necessary in order to administer oxygen.

Question 45

A DC amplifier is generally used to:

Answer 45

Record constant or slowly changing signals.
JUSTIFICATION:
DC amplifiers are superior for recording very slow potentials. In DC amplification, the LFF is infinite. The LFF, also referred to as the time constant, is the component of the amplifier that controls the speed in which a signal returns to baseline position. The LFF is useful for amplification and filtering of rapidly changing or high frequency activity. The filtering available to AC and not to DC amplifiers enables high resolution at rapidly changing signals.

Question 46

A child has an open tracheotomy for treatment of obstructive sleep apnea. Which of the following MUST be monitored during PSG for accurate respiratory event scoring?

Answer 46

Airflow at the tracheotomy.
JUSTIFICATION:
In order to identify respiratory events and classify them, it is essential to monitor airflow. In a patient with tracheotomy, although some flow can be present at the nose or mouth, most airflow will be via the tracheotomy. Therefore, measurement at the tracheotomy site is more important than measurement of nasal/oral airflow. Effort monitoring will be essential in this study, but there are several acceptable methods to accomplish this besides scapular or intercostals muscle measurement.

Question 47

Which of the following can interfere with the efficacy of high level disinfection of electrodes?

Answer 47

Inadequate cleaning prior to disinfection.
JUSTIFICATION:
If residual material is left on the electrode, the disinfectant will not contact the electrode surface. The target virus is removed through disinfection and cleaning the electrode prior to disinfection will not interfere in this process. Disinfecting agents are used for sterilizing working areas or equipment where contamination by infectious agent has or might have occurred. Disinfection is the inactivation of non-sporing organisms by heat and water (thermal) or by chemical means. Chemical disinfection does not kill spores. Sodium Hypochlorite is bleach and can be used to disinfect electrodes. Commonly used disinfecting agents fall into one of several categories, including: 1.ALDEHYDES- Glutaraldehyde and formaldehyde can be used in liquid or gaseous form and are effective against most microorganisms and viruses. Often the gas is more effective than the liquid. 2. ALCOHOLS (either ethanol or isopropanol to a 70% solution with distilled water). Alcohols are effective against a range of viruses. Gram-positive and Gram-negative bacteria including acid-fast bacilli but will not deactivate spores. Ethanol is far safer to use than other alcohols. 3. HALOGENS: Hypochlorites and bleaches are effective against viruses but are inactivated by protein and thus tend to be unsuitable for other microorganisms. 4. PHENOLICS: Are effective against Gram-positive and Gram-negative bacteria but generally will not deactivate acid-fast bacilli, spores, or viruses.

Question 48

To accomplish surface disinfection of electrical equipment, ___________ of the following should be used.

Answer 48

70% ethyl alcohol solution.
JUSTIFICATION:
A solution of only 10% ethyl alcohol has inadequate concentration to properly disinfect equipment. Dilute either ethanol or isopropanol to a 70% solution with distilled water, and allow contact for 30 minutes. Alcohols are effective against a range of viruses, both Gram-positive and Gram-negative bacteria including acid-fast bacilli, but will not deactivate spores. Ethanol is far safer to use than other alcohols.

Question 49

The activity seen in the leg EMG is:

Answer 49

Periodic limb movements of sleep.
JUSTIFICATION:
PLMS are repetitive episodes of muscle contractions, lasting 0.5-5.0 seconds separated by intervals of 5-90 seconds, occurring in a series of at least four movements. though many patients with PLMS also experience restless leg activity, these movements occur in wakefulness. Leg movements occurring in REM sleep usually do not maintain periodicity, and are not regular in appearance. If respiratory events occur prior to the onset of the leg movement, it should not be counted as a periodic limb movement in sleep.

Question 50

Reducing sampling rate will reduce file size and the archival process; however, the sampling rate should always be at LEAST ____ times the highest frequency of interest.

Answer 50

2-3.
JUSTIFICATION:
This is Nyquist’s Law, which states that the minimum sampling rate must be twice the frequency of the highest frequency waveform desired for analysis. In polysomnography, the sampling rate is the frequency with which the signal is reviewed for conversion to the digital signal. If a smooth reproduction of the signal is desired, a sampling rate exceeding the highest frequency by a factor of 10-20 is required. The commonly used sampling rate of 100Hz in PSG recordings allows minimally adequate visualization of waveforms up to 20-25 Hz.

Question 51

At the lights-off portion of a polysomnogram, patient should be instructed to:

Answer 51

Assume a comfortable sleeping position.
JUSTIFICATION:
When a satisfactory physiological calibration procedure is completed, lights in the patient’s room should be turned off and the patient should be instructed to assume a comfortable sleeping position. Options A, C and D are parts of the physiological calibration procedure that enables the technologist to determine the quality of data before the polysomnogram begins.

Question 52

Seizures can cause all of the following EXCEPT:

Answer 52

Fever.
JUSTIFICATION:
Likely forms of seizure to occur in sleep include generalized tonic-clonic seizures, partial seizures with motor symtomatology, and partial seizures with complex symtomatology. Fever is not an associated complication of any of these. Limb fractures, aspiration, and vertebral compression are all potential complications of generalized tonic-clonic seizures.

Question 53

Fuses and circuit breakers respond to wich of the following?

Answer 53

Circuit overloads.
JUSTIFICATION:
If a short circuit or circuit overload occurs, a fuse will blow or the circuit breaker will open and current will no longer flow. If a patient is connected to two or more pieces of equipment, each using a different ground, a voltage difference will cause current to flow though the patient. This is called a ground loop. To avoid this, all equipment should be plugged into outlets that share a common ground. Leakage current is a low level current that is present in an instrument. Stray capacitance and stray inductance are causes of leakage current.

Question 54

The minimum voltage criteria needed to identify a K-complex is:

Answer 54

There is no criteria.
JUSTIFICATION:
According to R&K, there is not a minimum voltage criteria for K-complexes. They must, however, have a minimum of .5 seconds duration. 75 microvolts is the amplitude criteria for delta waves seen in stage 3 and 4 sleep. Calibration voltage is unrelated to recorded activity.

Question 55

An elcectromyogram directly reflects the:

Answer 55

Depolarization of muscle fibers.
JUSTIFICATION:
Depolarization of muscle fibers leads to contraction of the muscle. The changes in polarization create variations of the electrical potential field at the skin surface that are detected by electrodes placed ove the muscles to be recorded. Dorsal root fibers are located in the spinal cord and require special evoked potential techniques to record. Hyperpolarization EPSPs and IPSPs of cortical neurons are related to EEG.

Question 56

The scoring criteria for stage 1 sleep include all of the following EXCEPT:

Answer 56

A decrease in the amplitude of the chin EMG.
JUSTIFICATION:
The EEG in stage 1 sleep is defined as a relatively low voltage mixed frequency background without rapid eye movements. It is characterized by a decrease in alpha activity to < 50% of the epoch. Sleep spindles and K-complexes are characteristics of stage 2 sleep. A decrease in chin EMG amplitude is a feature of REM sleep. Though a decrease is often seen in this transition, it is not part of the scoring criteria.

Question 57

The standard minimum duration for scoring an apnea/hypopnea in an adult is _____ seconds.

Answer 57

10 seconds.
JUSTIFICATION:
All accepted definitions for apnea and hypopnea in adults use a minimum duration of 10 seconds. There are several definitions for apnea/hypopnea in children, and a 6-second minimum duration criteria has been used in that population.

Question 58

If an amplifier had a 50 Hz notch filter, what effect would the filter have on a 35 Hz sine wave?

Answer 58

Frequency: No change
Amplitude: No change
JUSTIFICATION:
A notch filter significantly affects the amplitude of a narrow band or “notch” of frequencies only. For instance, a 50 Hz (generally less than 5 Hz plus or minus). All frequencies, except those close to the filter setting (50) will be completely unaffected. There will be no change in either frequency or amplitude.

Question 59

What type of montage will maximize EEG voltages recorded during all-night polysomnography?

Answer 59

Referential using contralateral ear reference.
JUSTIFICATION:
Differential amplifiers are used in polysomnography recording. What is displayed in a single channel is actually the difference between input 1 and input 2. A referential montage will display higher amplitude than a bipolar montage. Maximizing voltage is accomplished by having long inter electrode distances, with as much potential differences as possible.
This is best accomplished by having input 1 as physically far apart (long inter electrode distance) from input 2 as possible, and using a reference that will exhibit relatively little electrical activity (inactive reference) such as mastoids or ears. Transverse bipolar montages are connected as a chain going across the head (coronally). Anteroposterior bipolar montages are connected as a chain from the front to the back of the head. One would expect more common EEG activity with this type of montage than when using a contralateral reference, thus lower amplitude. Additionally, amplitude will be less because of shorter inter electrode distances. Though an averaged reference provides an adequate distance to obtain voltage differences, the averaged distance between the linked references cannot be as far from the site of interprets, because it averages a contralateral site with an ipsilateral reference site.

Question 60

Which of the following PSG findings may typically be seen in normal adult REM sleep?

Answer 60

Low-amplitude submentalis EMG
Low-voltage, Mixed-frequency EEG activity
REM sleep in normal adults is characterized by atonia, rapid eye movements, and low voltage, mixed frequency EEG. Delta frequency EEG activity is not associated with REM sleep. It is a feature of slow wave sleep.

Question 61

Sleep efficiency is defined as:

Answer 61

Total sleep time relative to total recording time.
JUSTIIFICATION:
Sleep efficiency is the total sleep time divided by the total recording time.
Total recording time is the period of time between lights off and lights on. Time elapsed from lights out to lights on is the same things as total recording time. Total time awake plus total sleep time is the same as time in bed.

Question 62

The recommended procedure for sterilizing virus-contaminated EEG electrodes is:

Answer 62

Bleach and water.
JUSTIFICATION:
Sodium hypochlorite (bleach) is considered a high-level disinfectant. The US Center for Disease Control says that semi-critical items, such as EEG electrodes, should receive high-level disinfect ion to deactivate viruses such as HIV, Hepatitis B, or tuberculosis. Steam autoclaving uses high levels of heat that could cause damage to electrodes. Gas sterilization is expensive and requires relatively long turn-around time. Gluteraldehyde is also an effective high-level disinfectant but its use is increasingly discouraged because of its toxicity and the prevalence of allergic sensitivity among patients and healthcare workers.

Question 63

The MOST important reason for monitoring limb movements from both the left and right anterior tibialis muscles is that movements:

Answer 63

Can occur in only one leg or can switch from one leg to the other throughout the night.
JUSTIFICATION:
Limb EMG recordings are important in patients with suspected PLMS and RBD. Leg movements can occur in only one leg or switch from one leg to the other. Thus, both legs should be monitored. It is important to distinguish respiratory related limb movements from “true” PLMS, but it is more important to be able to see all the movements. There is no data indicating that movements in one leg or the other occurs during specific times of the night. Although nocturnal seizures can be generalized or focal, and can be associated with tonic-clonic movements in one or both legs, limb movement monitors are not of particular significance or importance for the diagnosis of nocturnal seizures.

Question 64

All of the following statements are true about respiratory inductance plethysmography EXCEPT:

Answer 64

A current is generated when pressure is applied to the sensor.
JUSTIFICATION:
Inductance is a property of electrical conductors that is characterized by the opposition to a change of current flow in a conductor. Transducers, the physiologic equivalent of conductors, consist of an insulated wire that is sewn into an elasticized band. Though this method of monitoring respiratory effort is sensitive to artifact from position changes, calibrated inductance plethysmography does allow for detection of upper airway resistance. There is no current generated at any time using inductance plethysmography.

Question 65

Sleep period time is defined as total:

Answer 65

Sleep time and wake after sleep onset.
JUSTIFICATION:
The sleep period time (SPT) is the total sleep time (TST) plus wake that occurs between sleep onset and sleep off-set. Another way of stating this is the period of recording that excludes the sleep latency and wake between the end of sleep and lights on. Minutes of sleep is the same as total sleep time. Sleep time divided by the time in bed is called the sleep efficiency. The time from lights out to lights on is called time in bed (TIB).

Question 66

An alternate derivation for recording chin EMG would include which electrode placements?

Answer 66

Masseter.
JUSTIFICATION:
Although the chin EMG placement should be mental-submental, alternate placement on the masseter muscle could be used as a reference to one of the other chin electrodes in the event of difficulties with normal placements. Maxilla, mastoid and zygoma are bones and would be inappropriate placements for recording chin EMG.

Question 67

During the PSG, if the patient asks the technologist whether he has obstructive sleep apnea, the technologist should:

Answer 67

Suggest to the patient that information should be provided by the physician.
JUSTIFICATION:
The technologist should encourage the patient to talk to their physician for complete results of their polysomnogram. It is outside the technologist scope of practice to give any study results to the patient at any time, including diagnosis, information regarding physiologic data, and severity of abnormality.

Question 68

Which of the following alterations in sleep architecture is commonly seen in ICU patients?

Answer 68

Decreased REM.
JUSTIFICATION:
A variety of factors might a patient’s sleep architecture in the ICU, including the environment, medication, disease processes, and pain. Patients will likely show a decrease in REM sleep. Patients in the ICU will likely exhibit and increase in stage 1 and 2 sleep stages. patients in the ICU will likely exhibit a decrease in stage 3 - 4 sleep. Patients in the ICU will likely show an increase in the sleep onset latency.

Question 69

A patient who has been compliant with PAP therapy for four years stops by the laboratory during the day complaining of a persistent minor mask leak. The technologist should:

Answer 69

Review current mask options with the patient.
JUSTIFICATION:
Poor mask fit causing leakage of air into the eyes can result in conjunctivitis. Many different masks are available, with more being developed all the time. Allowing the patient to look at and try other mask options will increase the likelihood of patient satisfaction and compliance. Patients must be actively involved in their own treatments or PAP therapy will be less likely to be an effective therapy for them. Patient comfort will increase patient compliance. Increasing PAP should be by physician order. Air lek is not an indication for a repeat polysomnogram.

Question 70

During a MSLT the patient should be instructed that the following MUST be avoided between nap trials:

Answer 70

Caffeine and Napping.
JUSTIFICATION:
Both caffeine and napping can adversely affect the sleep latency and cause an artificial increase in sleep latency. They should be completely avoided during the time of the MSLT. Smoking can also affect sleep latency, but the half-life of nicotine is short. Restriction from smoking for 30 minutes prior to each nap trial avoids this effect. A patient may watch television, do puzzles, read, ect. as long as they stay awake between nap opportunities.

Question 71

Asystole noted on an ECG channel is confirmed by patient assessment. Which of the following should be the FIRST response?

Answer 71

Activate emergency response.
JUSTIFICATION:
The American Heart Association identifies activation of the emergency response system as the first response to increase the chance of patient survival. Asystole is a life threatening dysrhythmia, so intervention to improve the chance of survival is the only appropriate first response. Because asystole has already been confirmed by patient assessment, there is no reason to check the ECG electrodes. Initiating CPR and documentation are also correct responses, but would not be the appropriate FIRST response.

Question 72

During a PSG, all physiological signals are simultaneously replaced by flat lines. Which is the most likely cause?

Answer 72

Disconnected electrode input box.
JUSTIFICATION:
Disconnection of the electrode input box would result in loss of all signals derived from the electrodes. Seizure activity is typically associated with high amplitude physiologic activity. Cardiorespiratory arrest could be associated with some “flat line” signals, but would not cause all channels to go “flat” simultaneously. Loss of the ground electrode connection ca result in an increased amount of electrical artifact.

Question 73

Changes in sleep latency and sleep architecture that result from sleeping in an unfamiliar environment are termed:

Answer 73

First-nigh effect.
JUSTIFICATION:
Most research studies on sleep architecture allow an extra night to allow the patient to adapt to a new environment. The”first night” effect can increase sleep latency. Insomnia is a very broad term denoting unsatisfactory sleep and includes sleep onset insomnia, sleep maintenance insomnia, short sleep period and non-restorative sleep. Early onset REM can be seen in a variety of disorders, including depression, narcolepsy, obstructive sleep apnea or any other cause of REM sleep deprivation and is less likely to be seen in a strange sleeping environment. Delayed sleep phase syndrome is a circadian rhythm disorder where the timing of sleep onset is delayed relative to clock time.

Question 74

Which of the following would be LEAST appropriate to document?

Answer 74

The technologist’s impression of the patient’s medical history.
Justification:
The information that is documented by the technologist should be relevant and objective. Adding the technologist subjective opinion on the patient’s history is inappropriate and outside the technologist scope of practice. Any recent injury to the patient, unusual behavior while in the lab, difficulties with acclimating to sensors, and any other significant relevant information should be clearly documented. This might be of importance for the physician when reviewing data, and might affect patient outcome.

Question 75

During setup for a PAP titration study, a patient states that he has restless legs syndrome. The technologist should expect that a patient will have:

Answer 75

Difficulty initiating sleep.
Justification:
Restless leg syndrome is an intrinsic sleep disorder in which leg symptoms lead to difficulties with sleep initiation and can disrupt sleep. Restless leg syndrome does not have a direct affect on PAP tolerance. Alpha intrusion into sleep is not specifically associated with restless legs. Although elimination of obstructive sleep apnea with PAP can improve sleep architecture, it does not specifically improve the symptoms of restless leg syndrome.

Question 76

A patient describes symptoms of prolonged sleep periods associated with excessive food consumption and hypersexuality. The MOST likely cause is:

Answer 76

Kleine-Levin syndrome.
Justification:
Kleine-Levin is the only option that includes elements of both eating and hypersexuality. Although hypersexuality is not that common in these patients, hypersexuality has not been associated with Nocturnal Eating Syndrome. Munchausens syndrome is characterized by habitual pleas for treatment and hospitalization. It is not associated with eating or sexual behaviors. Nocturnal Eating syndrome involves uncontrolled eating that occurs during sleep. The patient usually has no recall of the event. This disorder is often secondary to either sleepwalking or Bulimia Nervosa. No association with hypersexuality has been found in this patient population. Lennox-Gastaut syndrome is a form of pediatric epilepsy with no associated eating or sexual behaviors.

Question 77

A 30-year-old male is being studied for EDS. Just prior to lights out, the patient admits to using marijuana 30 minutes ago and regular use 3 to 4 times per week. Which of the following might be anticipated while monitoring this patient?

Answer 77

Decreased slow-wave sleep.
Justification:
Sleep stage distribution is affected by ingestion of drugs prescribed for sleep as well as by other drugs that might not be prescribed for sleep. Although acute marijuana ingestion causes only minimal sleep disruption (decreased REM sleep), chronic use of the drug produces long-lasting inhibition of slow wave sleep. Chronic marijuana use causes decreased REM sleep. There is no documented evidence of marijuana’s effect on sleep latency. Chronic marijuana use causes only minimal sleep disruption.

Question 78

What is the predominant frequency range expected in the EEG channels during physiological calibrations of an adult patient who is awake with eyes closed?

Answer 78

8 to 13.5 Hz.
Justification:
During physiologic calibrations, the patient is instructed to close their eyes for a period of 30 seconds. Stage wake with eyes closed is typically accompanied by the presence of an alpha rhythm (8-13 Hz) seen predominantly in the occipital EEG leads. 2 - 3.5 Hz describes delta activity that would appear in slow wave sleep. 4-7.5 Hz. describes theta activity that would appear in stage 1 sleep. 14-16.5 Hz. falls within the beta range, and can be seen in waking with eyes open.

Question 79

Regular, repetitive stereotypical extremity muscle activity during sleep MOST LIKELY indicates which of the following?

Answer 79

Periodic limb movements.
Justification:
The key to recognition of periodic limb movements is the repetitive movement, typically occurring at intervals of 5-90 seconds with rhythmicity. Fragmentary myoclonus is measurable muscle activity occurring during sleep that is associated with very brief, highly localized EMG potentials. Restless leg syndrome occurs while the patient is awake, and is described as leg dysesthesias, provoked by rest, and associated with an urge to move. RLS is relieved by movement and can lead to difficulty with sleep initiation and sleep disruption. Hypnic jerks, also called sleep starts, occur during the process of sleep onset and consist of isolated brief body jerks.

Question 80

What is the activity noted in the LOC and ROC channels throughout the recording?

Answer 80

ECG artifact.
Justification:
This artifact is ECG and can be identified by recognizing that the frequency of the artifact is the same as the ECG channel. Sawtooth waves are a feature of REM sleep and are recognized as theta frequency waves with notched morphology appearing in the vertex region immediately preceding rapid eye movements. Eye blinks are common in the waking polysomnogram. Though they are often present in scalp channels, they are easily recognizable because similar activity is present in the EOG, but of increased amplitude. Vertex sharp waves are high voltage sharp transients appearing in the central leads predominantly in stages 1 and 2 sleep.

Question 81

The technologist observes a sudden onset of sinus arrhythmia. The MOST appropriate course of action is to:

Answer 81

Continue to monitor.
Justification:
Sinus arrhythmia is a benign change in heart rhythm that requires no specific intervention, emergency protocols, or immediate interaction with the physician. A variation in R-R interval does not imply a problem with EKG leads.

Question 82

A water column manometer is used to measure:

Answer 82

Air pressure relative to atmospheric pressure.
Justification:

Water and mercury column manometers have been determined as most appropriate for measuring pressure. The water column manometer with measurement in centimeters of water has been used as the standard for positive airway pressure measurement since the inception of PAP usage for treatment of sleep apnea. The measurement “centimeters of water” assumes pressure relative to surrounding air. This is a simple and relatively reliable measurement; pressure relative to a vacuum would not be. Though a flow is necessary to obtain pressure for a PAP flow generator, the measurement is of the resulting pressure. Once a closed-off, or relatively closed-off circuit such as a PAP system with a mask applied to the patient, is maintained, a pressure can be measured. Though there is a measurable volume of air produced by a flow generator in a PAP circuit, what is measured is the resulting pressure that is maintained by the entire circuit, concluding with the fit of the interface to the patient.

Question 83

A PSG is being recorded on a two-year-old. The technologist notes gradually increasing muscle artifact during stage 3/4 sleep. The parent has temporarily left the room. The patient’s eyes are closed and the patient is moaning, thrashing, and perspiring profusely. The technologist’s BEST response would be to:

Answer 83

Move to the bedside until the episode subsides.

Justification:
These events are consistent with confusional arousals. The technologist should move to the patient’s bedside to keep the patient from injury. The episode should be allowed to follow the natural course to aid in diagnosis of the patient’s sleep disorder. Adjusting filters to eliminate artifact would also likely eliminate or significantly reduce any abnormality that is present in the recording, and would waste valuable time in a situation where the potential for injury is present. Holding the child can actually cause injury to the patient. In fact, the more parents or technologists try to intercede, the longer the episode might last. The technologist should not leave the patient unattended. Patients experiencing confusional arousals do not recognize people (even parents) during the spells.

Question 84

A uniform method to protect patients and personnel against infectious disease will require:

Answer 84

High level disinfection of all electrodes used in sleep studies.

Justification:
Standard precautions should be followed with all patients in the sleep laboratory. Procedures for using EEG surface electrodes require that electrodes be cleaned with a detergent or ultrasonic cleaning to remove residual solid material, and then soaked in a disinfectant solution. Treatment of skin breaks is not generally inappropriate, but it is not part of standard precautions to prevent the spread of infection. Acetone is not a disinfectant. It is not necessary to keep two sets of electrodes for each patient as long as standard precautions are followed.

Question 85

Prior to scoring a PSG, the technologist reads that the patient has a history of musculoskeletal pain. The technologist should anticipate a possible increase in:

Answer 85

Alpha.

Justification:
Alpha-delta sleep is characterized by persistence of alpha activity during stages 3 and 4 sleep. Excessive alpha intrusion can be seen in stage 2 as well. This might indicate the presence of increased alpha, which is more commonly seen in patients with fibromyalgia syndrome and other patients experiencing chronic pain or discomfort. Increases in beta are common with certain medication use, but not directly related to pain. Increases in delta and theta are not usually associated with chronic musculoskeletal pain or fibromyalgia.

Question 86

What sleep disorder is associated with intermittent interruptions of REM sleep related atonia, and intense dream mentation?

Answer 86

REM behavior disorder.

Justification:
In normal individuals, during REM sleep there is atonia of all skeletal muscles (excluding the diaphram and eye movement muscles). In REM Sleep Behavior Disorder (RBD) there is an absence of REM sleep atonia that permits the “acting out” of dreams, often with dramatic and violent behaviors. Nocturnal paroxysmal dystonia has characteristic violent movements but is not related to REM sleep. Nocturnal myoclonus is an archaic term for periodic limb movement disorder, and is generally a NREM phenomenon. Advanced sleep phase syndrome is not associated with intrinsic sleep architecture abnormalities other than a circadian shift.

Question 87

According to AASM Standards of Practice, the minimal PSG recording channel requirements for evaluating sleep-related breathing are:

Answer 87

EEG, EOG, chin EMG, SpO2, effort, airflow, and ECG or heart rate.

Justification:
EEG, EOG, and chin EMG are necessary for sleep staging. Oxygen saturations, respiratory effort and airflow and ECG parameters are important to monitor for identification of respiratory events and the physiologic changes that occur with them. Though an important part of standard polysomnography, limb monitoring is not essential for evaluating sleep-related breathing.

Question 88

Accreditation standards for the computerized recording of polysomnograms stipulates that _______ must be present for storage?

Answer 88

Raw data.

Justification:
Accreditation standards require inclusion of channels for oximetry and ECG, and that the entire recording, including pre and post sleep calibration, be digitized and stored. This must be raw data, not summarized results. Should there be a need for review of the data for any purpose, it is necessary for raw data to be available to accomplish this. Data might be summarized in a report, but the raw data must be available for review by the sleep specialist. A patient history is important but requires no extra processing for computerized systems.

Question 89

When providing an in-service to nurses on recognizing sleep disorders in hospitalized patients, it would be important to mention that:

Answer 89

Patients on nasal CPAP should use this therapy in postoperative and peri-procedural periods.

Justification:
Patients on PAP therapy could actually need an increase in the pressure requirements in the presence of narcotics and general anesthesia. Anesthesia can also promote upper airway instability by selectively reducing innervations to the upper airway muscles. Patients should use their PAP at all times, but it is even more important when hospitalized. Loud snoring is one of the most common signs of sleep apnea, and though common, loud snoring is not normal. Physicians might not recognize the signs and symptoms of obstructive sleep apnea.

Question 90

A patient presents in the sleep laboratory with a five-year documented diagnosis of HIV that is controlled by immuno-suppressive medication. What considerations would be required to render care to this patient?

Answer 90

Practice standard precautions.

Justification:
Use standard precautions for the care of ALL patients. Standard precautions apply to blood, all body fluids, secretions and excretions except sweat, whether there is visible blood or not. Standard precautions also apply to non-intact skin and mucous membranes. It is inappropriate to reveal any patient information to another patient. It is not necessary to reschedule the patient if standard precautions are followed. It is not practical or necessary to use disposable equipment on patients.

Question 91

Necessary information that should be included on a pre-sleep questionnaire is:

Answer 91

Sleepiness scale, medication history, and alcohol intake.

Justification:
Sleep quality and sleep disturbance is dependent on several factors. A complete history is important to determine which factors might be affecting a patient’s sleep when presenting for a sleep evaluation. The sleepiness scale provides insight into the patient’s assessment of how alert he/she feels and is used to determine the level of daytime sleepiness. Because various medications, as well as alcohol ingestion, affect sleep quality and sleep stage distribution, it is vitally important to collect a medication and alcohol history on the sleep patient prior to the sleep evaluation. Dream history, smoking history, and allergy history can be important information, and might be included as part of the general history, physical and/or questionnaire, but are not specifically included in the pre-sleep questionnaire.

Question 92

In addition to excessive daytime sleepiness, the most significant sign for a clinical diagnosis of narcolepsy is which of the following?

Answer 92

Cataplexy.

Justification:
A history of current or past cataplexy is an essential diagnostic feature of narcolepsy. Sleep onset dreams (hypnagogic hallucinations) are common among narcoleptics but are not essential for the establishment of the diagnosis. Symptoms similar to REM sleep behavior disorder are sometimes associated with drugs used to treat cataplexy but are not specifically symptoms of narcolepsy. Sleep paralysis is the inability to move or speak, although consciousness and the ability to recall the event are maintained. Although considered to be one of the tetrad of symptoms, sleep paralysis is not essential for the diagnosis of narcolepsy

Question 93

An elderly patient living independently calls the sleep lab complaining of difficulty using the PAP equipment including humidifier set-up, PAP unit placement and mask adjustment. The BEST course of action is to:

Answer 93

Request a repeat in-home visit from the therapist.

Justification:
“Home Medical Equipment” or “Durable Medical Equipment” companies dispense most home PAP units and related accessories. These companies typically employ specialists who are trained in the area of PAP education, as well as providing solutions for low PAP compliance. The best course of action when responding to patient complaints and compliance problems is to arrange for a visit with the PAP specialist. Because an important part of home use is the actual environment in which the patient is to use the equipment, it is important to take these factors into consideration when addressing problems. Interventions typically include re-training and mask size or type revision. If this step fails, then a visit with a physician would be appropriate. Family members, although often well meaning and willing to help, are less knowledgeable and do not have resources available to effect change. Encouraging the patient to keep trying without intervention can result in the patient becoming discouraged and poor patient PAP compliance.

Question 94

Interictal activity of spike and sharp waves during sleep occurs more often during:

Answer 94

NREM.

Justification:
Interictal is the electroencephalographic pattern that occurs between epileptic (ictal) seizures. Interictal epileptiform discharges tend to increase during non-REM sleep and are suppressed during REM sleep. Obstructive sleep apnea and decreased saturations have no effect on interictal epileptiform activity, although these events can be triggers for ictal events.

Question 95

The technologist has noticed that CPAP masks are not being cleaned properly based on established lab protocol. Following BRPT Standards of Conduct, what is the MOST appropriate course of action?

Answer 95

Inform the supervisor or infection control manager.

Justification:
Failure to follow sleep laboratory protocols for infection control violates the BRPT Standards of Conduct for Registered Polysomnographic Technologists. The standards require that RPSGT’s “maintain the highest of professional and ethical standards.” One requirement is to “keep the health and safety of the patient in mind at all times and act in the best interest of the patient.” It would not be necessary to report this to the BRPT, but should be reported to the supervisor and/or infection control manager, which would include documentation. This avenue is more likely to affect policy change. Re-used CPAP masks should always be disinfected and cleaned following laboratory protocol.

Question 96

46 Which stage does this epoch represent?

Please click the “Attachment” button above to view the accompanying graphic.

Answer 96

2.

Justification:
Stage 2 is defined by the presence of sleep spindles and/or K-complexes and the absence of sufficient high amplitude, slow activity to define the presence of Stages 3 and 4. Vertex waves might be present. Stage 1 is defined by a relatively low voltage, mixed frequency EEG with a prominence of activity in the 2-7 cps range. Stage 3 is defined by the presence of 75-microvolt delta activity that occupies 20-50% of the epoch. Stage REM is defined by the appearance of relatively low voltage, mixed frequency EEG and episodic REMs. Sawtooth waves might be present.

Question 97

What electrode is represented by the letter F?

Answer 97

F7.

Justification:
This represents a diagram of the International 10-20 System of Electrode Placement. F7 is placed on the circumferential plane, 10% between electrodes Fp1 and T3. The Fp locations are frontal pole locations on the forehead. Even number locations are on the right side of the head.

Question 98

The abnormality represented in this epoch is:

Answer 98

Mixed apnea.

Justification:
Mixed apnea is identified when respiratory effort returns before respiratory flow returns. Obstructive apnea is cessation of flow while respiratory effort continues. Central apnea is the cessation of flow and effort occurring at the same time. Cheyne stokes is a type of central apnea that is identified by the rhythmic waxing and waning of effort and flow.

Question 99

Given an input signal of 100 ¿V and a sensitivity of 20 ¿V/mm, what is the amplitude of the output signal deflection?

Answer 99

5 mm.

Justification:
Signal deflection can be calculated using the formula V / S = D ( V = voltage, S = sensitivity, D = deflection or amplitude) and gives the result 100 / 20 = 5. The voltage of any EEG waveform is computed by multiplying its amplitude (in mm) by the sensitivity (5 x 20 = 100).

Question 100

Which of the following statements is INCORRECT regarding the use of acetone?

Answer 100

Acetone can be used to sterilize electrodes.

Justification:
Acetone is a solvent and does not contain any sterilizing agents. It cannot be used to disinfect or sterilize electrodes or any other equipment. It can be used to remove surface oils on the patient’s scalp/skin prior to electrode application. Acetone is highly flammable and can easily ignite and burn rapidly. It can also be toxic and exposure to acetone can cause respiratory, skin and eye irritation.