Imaging with X-rays:

Questions AND Answers

1. Regarding the use of contrast media:
a. Radio-opaque contrast media agents are chosen because their atomic
number is chosen to maximize the absorption of a diagnostic X-ray beam by
the Compton effect
b. The absorption energy/K-edge of iodine is 53 keV
c. Bone and iodine demonstrate a similar computed tomography
(CT) number because they have a similar atomic number
d. High-density and low-density contrast agents can be administered
together in certain circumstances to improve image contrast and quality.
e. A positive contrast agent should ideally have K-edge energy equal to the
characteristic radiation emitted from the X-ray tube
Answers
a. False ___
Radio-opaque contrast media is chosen so that the high atomic number
maximizes photoelectric absorption of the beam. The K-edge energy of the
contrast medium should be slightly less than the major part of the X-ray
energy spectrum to maximize this effect.
b. False
The atomic number of iodine is 53; its K-edge energy is 33 keV.
c. False
The atomic number of iodine is 53. The atomic number of bone is
approximately 13. In tissues, CT number is related to electron density which
itself is closely related to physical density. However, in higher
Z materials such as iodine there is significant attenuation due to the
photoelectric effect and therefore iodine will have a higher CT number than
bone even though the physical density is less than that of bone.
d. True
An example is a barium enema, where barium and air are used to
demonstrate the mucosal anatomy of the colon. Air has been used much less
 as a contrast agent in other areas of radiology since the introduction of CT
and magnetic resonance imaging (MRI).
e. False
The K-edge should be slightly less than the beam energy. If they are exactly
the same then the contrast media will not attenuate the beam.
Substances are relatively ‘transparent’ to X-rays with energy just below their
K-edge. This property is utilized when filtering X-ray beams.

2. Concerning factors that affect radiation dose:

a. The entrance surface dose of an anteroposterior (AP) pelvic X-ray is
approximately 10 times greater than the dose to the imaging plate.
b. To achieve a similar dose to the imaging plate, an 85 kV beam will result
in a greater entrance surface dose than a 65 kV beam
c. Additional beam filtration generally improves image quality but increases
the patient dose
d. Increasing the focus–detector distance reduces the dose to the patient.
e. The use of an anti-scatter grid can reduce the dose to the patient
Answers

a. False ___
The entrance surface dose of a pelvic X-ray is far greater than 10 times the
exit dose as most of the beam is absorbed by the patient.
Approximate imaging plate: entrance dose ratios are – posteroanterior
(PA) chest X-ray (CXR) 1:10, skull X-ray 1:100, AP pelvis 1:1000, lateral
lumbar spine X-ray 1:5000 (the actual exit doses are greater due to scatter;
these figures are those you would get when the scatter radiation has been
removed by the grid).
b. False
A beam with a higher kV will be more penetrating which increases the
proportion of high-energy photons that reach the imaging plate. This means
that a lower tube current can be used to achieve a similar degree of film
blackening and therefore entrance surface dose will be less.
c. False
 Photons at the low energy end of the spectrum contribute nothing to image
formation but are absorbed by the patient. By using a filter these can be
removed from the beam. The patient's dose is lowered as a result.
d. True
Increasing the focus–detector distance results in less attenuation between the
skin surface and the imaging plate. This means proportionately less
attenuation according to the inverse square law, i.e. the skin dose
can be reduced for the same dose to the detector.
e. False
An anti-scatter grid is situated between the patient and the film–screen.
It absorbs some of the radiation beam and therefore a higher tube
current is required to achieve adequate film exposure. This results
in an increased patient dose.

3. Contrast and spatial resolutions:

a. Spatial resolution may be measured in line pairs per millimetre.
b. Spatial resolution is unaffected by the contrast of the objects being imaged
c. Image quality refers to spatial resolution but not to contrast resolution
d. Contrast is the ability to differentiate between structures within the image
e. Subject contrast increases with an increased thickness of the imaged organ
Answers

3a. True ___

It may also be expressed as the size of the smallest visible detail in
millimetres, which would be the width of one line from each line pair.
3b. False
Spatial resolution is best when imaging high-contrast structures.
3c. False
Image quality is a generic term that refers to the accuracy of the image in
both contrast and spatial resolutions.
3d. True
The bigger the difference in attenuation within each structure, the more
visible is the change in greyscale.
3e. True
 In projection imaging such as radiography and fluoroscopy, the contrast will
increase with a greater thickness of the organ, as more of the difference of
attenuation of the beam will be due to the organ of interest. It is decreased
by a greater thickness of overlying soft tissue as this will average out the
difference of the beam attenuated by the organ.
In CT the contrast is essentially independent of the overlying soft tissue.

4. Imaging geometry:
a. Distortion is greater with a larger focus–film distance
b. Geometrical unsharpness occurs with round-edged objects
c. Object–film distance is directly related to unsharpness
d. Magnification in mammography is achieved by increasing object–film
distance
e. An ideal set-up would minimize focal spot size, maximize focus–film
distance and minimize object–film distance
Answers

4a. False ___

Increasing the focus–film distance makes the beam more parallel thereby
reducing distortion.
4b. False
Geometrical unsharpness is caused by the penumbra effect where
X-ray intensity changes gradually across a sharp-edged object. The
penumbra occurs because the X-rays do not arise from a true point source,
i.e. it is worse with larger focal spots. Round-edged objects cause absorption
unsharpness.
4c. True
The penumbra effect is also worse with increased object–film distance.
4d. True
This occurs through greater divergence of the transmitted beam.
4e. True
All act to reduce beam divergence.
5. Unsharpness:
a. Screen unsharpness is the product of movement unsharpness and
geometric unsharpness
b. Geometric unsharpness can be reduced by the use of an air gap
c. Movement unsharpness is approximately equal to the speed of movement
of the object multiplied by the time of exposure
d. Absorption or edge unsharpness is produced around the edge of
a tapered or rounded structure such as a blood vessel
e. Movement unsharpness can be a significant problem in mammography
due to longer exposure times
Answers

5a. False ___

Screen unsharpness is unsharpness caused in the screen by spread
of light within the phosphorus material. Total unsharpness is approximately

5b. False
An air gap reduces scatter reaching the film or detector plate, but it increases
geometric unsharpness as the photons have further to travel after attenuation
within the object and thus can diverge more.
Geometric unsharpness can be reduced by a longer focus-to-object
distance, a shorter object-to-film distance, and a smaller focal spot.
5c. True
This assumes that the object is travelling at a steady velocity and that the
divergence of photons between the object and film or detector plate is
minimal. Movement unsharpness can be reduced by asking the patient not to
move and hold their breath, immobilizing the patient, and using a shorter
exposure time.
5d. True
This occurs due to differential photon attenuation across a rounded edge.
5e. True
Exposure times in mammography can be more than one second. One reason
for using compression is to limit patient movement.
6. Noise and signal-to-noise ratio (SNR):
a. Quantum noise or mottle is due to random variation in the number of
photons being detected.
b. Electronic noise is predominant in CT
c. Noise is commonly expressed as a proportion of the total number of
photons detected in a single area or pixel (M), as 1/M1/2
d. SNR is defined as M/M1/2
e. Structural noise is caused by random background radiation from the
patient and structures near the film or detector plate
Answers
6a. True ___
The detection of individual photons is a random process. When only very
small numbers of photons are detected, this statistical difference is a
significant proportion of the whole and is represented as a variance in the
density of the film or the value given to the pixels.
6b. False
Quantum noise is predominant in all X-ray imaging due to the requirement
to keep doses as low as is reasonably practicable (ALARP).
Electronic noise is predominant in ultrasound.
6c. True
Although with increasing numbers of photons the variation in numbers
detected does increase, this variation as a percentage of the total number of
events detected decreases. Thus the noise decreases with increasing dose to
the patient, or increased efficiency in detecting photons, or thicker phosphor
material, etc.
6d. True
SNR increases in proportion to the square root of the number of photons
detected.
6e. False
Structural noise is caused by variations in the structure of the screen
phosphor. In modern, precisely made phosphors structural noise is
negligible.
7. The quality of the X-ray beam is hardened by:
a. Increasing the tube kV
b. Decreasing the focus to film distance
c. Increased thickness of aluminium filter
d. Increasing the tube mA
e. Increased thickness of the intensifying screen
Answers
7a. True ____
Increasing the kV will result in more high energy photons being produced
which will result in a more penetrating or ‘harder’ beam.
7b. False
Focus to film distance has no significant effect on the quality of the beam.
Air will very slightly attenuate the beam to make it slightly harder, but at the
distances used in radiology, this effect is negligible.
7c. True
Increasing the thickness of the aluminium will attenuate more of the lower
energy photons; the exiting beam will have a 55higher average photon
energy.
7d. False`
This will result in more photons, but the photons will still have the same
proportion of energies as long as the kV remains the same.
7e. False
Increased thickness of screen will allow more photons to be absorbed thus
allowing a reduced dose at the expense of more screen unsharpness and
increased noise. It will have no effect on the quality of the beam unless the
kV is changed.
8. Scatter and grids:
a. Scatter predominantly affects spatial resolution
b. Increasing the kV reduces the scatter reaching the plate or detector
c. Grid techniques reduce scatter reaching the film or plate
d. Grid techniques increase image contrast resolution
e. Grid techniques reduce patient dose
Answers
8a. False ___
Scatter falls randomly across the entire image increasing the overall level of
grey in the picture. This is similar to a film with a higher base fog and
reduces the contrast seen in the image. While spatial resolution is affected
(especially of low contrast structures) reduction in contrast is far more
significant.
8b. False
Increasing the kV may allow a reduction in the patient dose for the same
detector, but the beam becomes more penetrating. A greater proportion of
the scatter therefore is formed at the exit side of the patient and so more
scatter reaches the imaging detector.
8c. True
The grid predominantly absorbs scatter and allows most of the primary beam
to pass through. As higher doses are required, however, the amount of
scatter formed within the patient is actually increased.
8d. True
As the grid reduces scatter reaching the detector, the contrast resolution will
improve.
8e. False
Grids significantly reduce the amount of radiation reaching the detector and
therefore require a higher dose.

9. Use of compression:
 a. Reduces attenuation of the beam
b. Reduces scatter
c. Reduces contrast seen in the organ being imaged
d. Requires a high kV technique
e. Is only used in mammography
Answers

9a. True ___

Compression reduces the thickness of material through which the beam
travels, so reducing the attenuation of the beam.
9b. True
As the beam passes through less tissue there are fewer Compton interaction
events and therefore less scatter is produced.
9c. False
Not only is the amount of scatter reduced thus improving contrast, there is
less overlying soft tissue above and below the organ or region of interest.
The differing attenuation of the organ therefore becomes more pronounced
as it is not superimposed by other soft tissues.
9d. False
As attenuation is reduced, exposure settings can either be left unaltered for a
better quality of image or be reduced. They do not need to be increased.
9e. False
Compression is commonly used in mammography, but it may also be used
in other settings. Intravenous urography (IVU) studies and abdominal
radiographs in large patients would both be examples where compression
may be useful if there are no contraindications.

10. Tubes and heating:

 a. X-ray tubes contain a cathode and an anode
b. The electron beam is emitted from the anode after bombardment of the
target
c. An increase in angle of the target decreases the effective focal spot size
d. The focusing cup refers to the target area of the anode
e. Heat loading of the tube is the product of kV and mAs and is measured in
joules
Answers

10a. True __
The cathode is the filament and the anode contains the target.
10b. False
The electron beam is emitted from the cathode and bombards the anode
target to produce X-rays.
10c. False
An increase in angle would result in a larger effective focal spot size.
10d. False
The focusing cup refers to the shaped part of the cathode that focuses the
electrons emitted from the filament towards the target.
10e. True
For older single phase generator systems the average kV is lower and heat
loading is calculated using 0.7 X kVp X mAs.

11. For rotating anodes:

 a. The rotator bearings are lubricated with a metal such as silver
b. The anode mainly loses heat via conduction through a molybdenum (Mo)
stem
c. The anode completes one full rotation in the exposure time to evenly
spread the heat along the focal spot track
d. The edge of the anode disk is rounded
e. Typical effective focal spot sizes would be 0.6–1 mm for general
radiography and 0.1–0.4 mm for mammography
Answers

11a. True ___

A metal such as silver in powder form may be used. Conventional liquid
lubricants would evaporate in a vacuum.
11b. False
Heat loss via conduction occurs in stationary anodes. In rotating anodes a
poor heat conductor such as molybdenum is used as the stem to reduce the
chance of heat damage to the bearings. Heat is lost via radiation from the
blackened disk to oil around the vacuum casing.
11c. False
The anode disk rotates at a fixed speed which may be as fast as 9000 rpm to
evenly distribute heating around the track.
11d. False
The disc is bevelled to provide a surface at an angle. The smaller the angle
theta the smaller is the effective focal spot size.
11e. True
The smaller size used in mammography allows better resolution in the
image.

12. Concerning generators:

 a. Three phase generators produce a higher kVp than single phase generators
b. Single phase generators require longer exposure times for the same kVp
and mA settings
c. Modern high frequency generators produce a relatively stable voltage so
kV can be assumed to be equal to kVp
d. Self rectifying generators are used in modern X-ray equipment and
produce a higher mean kV than three phase generators
e. High frequency generators produce a harder more penetrating beam at the
same kVp
Answers

12a. False ___

Three phase generators produce a higher average kV but the kVp is
unaltered.
12b. True
As the average kV is lower in single phase generators, a higher mA or a
longer exposure time is required.
12c. True
High frequency generators are used in most modern diagnostic X-ray sets.
12d. False
Self rectifying generators are still commonly used for dental intraoral
radiography. They work on the principle that the X-ray tube current can only
flow in one direction, and thus for half the exposure time the tube is
switched off. This obviously lowers the average kV, and requires
significantly longer exposure times.
12e. True
As the kV across the X-ray tube is always within a few percent of the
maximum, the peak of the X-ray spectrum will be shifted to the right and the
quality of the beam will be more penetrating.

13. In quality control of X-ray equipment and procedures:

 a. At 70 kV a half-value layer (HVL) of 2.5 mm aluminium would be
expected if there was adequate filtration
b. kV can be measured using a penetrameter
c. A Leeds test object is used for quality control in fluoroscopy
d. Quality assurance (QA) for lead aprons may include taking an
X-ray image of them to check the lead lining is intact
e. The image distortion of an image intensifier can be assessed using a
rectangular grid
Answers

13a. True __
The minimum filtration required is 2.5 mm of aluminium for which the
HVL in aluminium is approximately 2.5 mm. At 125 kV the HVL would be
much greater at about 4.5 mm.
13b. True
This is a device that estimates kV by measurement of the differential
transmission of the beam through different filter thicknesses. A direct
reading of kV can be made using a potential divider, but the less invasive
and more commonly used method is with a penetrameter.
13c. True
This consists of many circular details of different diameters and thickness.
13d. True
Tears due to the apron being incorrectly stored may show as lines of X-ray
exposure on a film or detector plate.
13e. True
Geometrical distortion is easily identified in this manner.
14. Further QA of X-ray equipment and procedures:
a. A densitometer measures the density of anode target material
b. A QA programme should ensure that tests are done consistently at agreed
time intervals according to a written protocol
c. Audit is a requirement of QA
d. Discrepancies of up to 10 mm of collimation of a 20 cm square test plate
at 1 m would be acceptable
e. Different dose area product (DAP) values for similar examinations may
indicate a difference in the equipment or the operators
Answers

14a. False __
This is a device for measuring optical density of film.
14b. True
Any deviation greater than agreed levels is reported to a manager
responsible for remedial action.
14c. True
This is a requirement under Ionising Radiation (Medical Exposure)
Regulations (IR(ME)R).
14d. True
This roughly equates to 10% error.
14e. True
Auditing patient dose for a large patient sample in order to reduce the effect
of patient-to-patient variation can demonstrate the effects of equipment
differences, operator technique, or differences in patient groups (e.g. elderly
versus young adult).

15. Film chemistry:

a. Film emulsion is a suspension of silver halide crystals
b. Film for general radiology normally consists of a polyester base with an
emulsion backing on one side
c. The film emulsion layer is only approximately 0.5 mm thick
d. Each crystal is about 1 mm diameter
e. The emulsion is only responsive to ionizing radiation of about
1 keV and above
Answers

15a. True __
Generally the silver halide is approximately 10% bromide and 90% iodide.
15b. False
Single-sided films are used where spatial resolution is paramount such as in
mammography. For general radiography there is emulsion on both sides of
 the base and two intensifying screens are used to maximize sensitivity to X-
rays.
15c. False
The emulsion layer would typically be 5–10 mm thick.
15d. True
Crystal size affects film speed and gamma, but is typically in the region of
1 mm diameter.
15e. False
The silver halide crystals are most responsive to visible light; this is why
intensifying screens are used. They are relatively insensitive to X-rays.

16. More film chemistry:

a. Gamma depends on the variation in crystal size
b. Gamma increases with temperature and developer concentration
c. A high gamma film has a wide latitude
d. Development of the film involves reduction of the silver ions by an acid
fixing agent
e. A brown vinegary film may be caused by inadequate washing
Answers

16a. True __
A large variation in crystal size results in a low gamma film while a more
uniform crystal size results in a high gamma film. A greater average size of
crystals results in a faster film.
16b. True
Although at higher temperatures and concentrations the effective gamma
may reduce because of the increased film fog.
16c. False
The higher the gamma of the film the more reduced the useful exposure and
thus the latitude.
16d. False
Development of the film is by an alkaline reducing agent which reduces the
silver bromide crystals that have been affected by exposure to light into
grains of metallic silver. Fixing occurs after this and involves an acid
 solution such as thiosulphate to dissolve out unaffected silver ions so that the
film is no longer susceptible to light and radiation.
16e. True
This adds to fog and decreases the contrast of the film.

17. Speed, density and noise:

a. Speed is equal to 1000 divided by the air kerma (in mGy) required for
density 1 above base plus fog
b. Typical speed for a rare earth film–screen combination would be about
400
c. Quantum sink refers to the random attenuation of X-ray photons in the
patient causing scatter
d. Optical density (OD) of film is log10 (transmitted light/incident light)
e. An OD of 5–10 would be typical for bony structures on an adequately
exposed film
Answers

17a. True ___

Speed of a film–screen combination changes with different factors such as
X-ray beam quality, so speed measurements are given for a specific
radiation quality.
17b. True
This is calculated as speed = 1000/air kerma.
17c. False
The quantum sink is the part of the process where the image is carried by the
least number of photons. It is this phase where the statistical variation in
photon absorption and thus noise will be greatest in comparison to the
signal. In film–screen radiography, the quantum sink is at the stage of X-ray
photon absorption in the phosphor.
17d. False
OD = log10 (incident light/transmitted light).
17e. False
An OD of about 1 is ideal for most areas of interest. The higher the OD the
blacker the appearance of the film. An OD of 2 might be seen in imaging of
 the lung. ODs of greater than 2.5 are normally too dark to discern any detail.
Bones appear light with density generally less than 1.
18. Film–screen:
a. Rare earth materials are used for intensifying screens as their
K-edges are in the diagnostic range
b. Intensifying screens utilize thermoluminescence
c. Up to two intensifying screens might be used
d. Characteristic curves are plotted with OD against exposure
e. Film gamma is measured as the average slope of the characteristic curve
Answers

18a. True __
A commonly used example is gadolinium oxysulphide which has a
K-edge of around 50 keV.
18b. False
Typically, screens undergo fluorescence with instantaneous release of light
with an intensity which is proportional to the X-rays incident on the screen.
Thermoluminescence means light is released after heating.
18c. True
In general radiography there is an intensifying screen on either side of the
double emulsion film. In mammography where a higher resolution is
required, only one screen and corresponding emulsion are used.
18d. False
They are plotted as OD against the log of exposure.
18e. True
A steeper slope represents a larger film gamma.

19. Further film–screen:

a. An acceptable level of base plus fog has an OD of 0.5
b. A film–screen combination with a high gamma will have a relatively wide
latitude
c. Ideally an intensification screen should be as thick as possible
d. A phosphor with greater X-rays to light conversion will be associated with
more noise than an equally sensitive phosphor with a lower conversion
efficiency but a greater thickness
 e. Crossover is impossible if a single side of film emulsion is used

Answers

19a. False ___

It should be around 0.15–0.2.
19b. False
A high gamma implies a narrow range of exposures between black and
white in the image; this is equivalent to a narrow latitude.
19c. False
The thickness is a compromise between sensitivity and unsharpness. It needs
to be thick enough to efficiently absorb X-ray photons. This is balanced
against unsharpness, however, since interactions occurring further from the
film will lead to greater spread of the produced light.
19d. True
A balance has to be struck; for the same detection efficiency a better
phosphor will increase noise, while a thicker one will increase unsharpness
without increasing noise. The greater the X-ray to light conversion factor,
the lower the number of photons detected to get the same OD. The quantum
noise in the image is inversely proportional to the number of photons
detected.
19e. False
Crossover refers to light from one screen affecting the opposite emulsion.
Parallax means two emulsions produce two slightly different superimposed
images; this is impossible therefore with a single emulsion.

20. Intensifying screens:

a. Intensifying screens reduce dose but increase noise for the same amount
of film blackening
 b. Without an intensification screen, only about 20% of the X-ray photons
would be absorbed by the film
c. Intensification factor is the ratio of kerma for a film density of
1 with and without the intensifying screen
d. Rare earth screens are used because of their very high atomic number
e. A thicker phosphor layer decreases dose required at the expense of greater
noise and screen unsharpness
Answers

20a. True ___

The intensifying screen essentially amplifies the number of photons detected
by the film and so produces a much darker image for the same dose. This
means that significantly fewer X-ray photons are detected for the same level
of OD and therefore the noise is increased.
20b. False
Film alone absorbs only about 2% of X-ray photons.
20c. True
Intensification factor is typically in the range of 30–100.
20d. False
Rare earth elements such as gadolinium actually have lower atomic numbers
than tungsten used in traditional screens. The advantage of rare earth screens
is a K-edge that is closer to the average energy of diagnostic X-ray
spectrums than the K-edge of tungsten. In addition the rare earth phosphors
produce greater light output for each X-ray photon detected.
20e. False
A thicker phosphor layer absorbs more photons. As more photons are
absorbed, dose can be reduced proportionately so that the same OD can be
achieved at a lower dose with no increase in noise.
However, light spreads further within the phosphor layer and so screen
unsharpness is increased.

21. In mammography:
a. A K-edge filter such as molybdenum is commonly used
 b. The filter should not be the same element as the anode target otherwise
the characteristic radiation would be absorbed
c. Typical spatial resolution for both digital and film mammography is 15
lp/mm
d. Typical mean glandular breast dose is 1.5–3 mGy for a single exposure
e. Typical kV for mammography is 24–35 kV
Answers

21a. True ___

Molybdenum and rhodium are the most common.
21b. False
The K-edge of an element is just higher than its characteristic radiation,
therefore any element is relatively transparent to its own characteristic
radiation. Mammography exploits this by commonly using molybdenum as
both the anode target and the filter. A molybdenum filter should not be used
with a rhodium target as the maximum absorption energies in the filter
would correspond to the energy of the characteristic radiation from the
target.
21c. False
Film mammography does achieve 15 lp/mm. The pixel size in digital
radiography systems for mammography is generally not less than about
70 mm corresponding to 7 lp/mm. However, smaller high contrast details
(micro-calcifications) may be seen due to the partial volume effect and the
other advantages of digital systems, particularly post processing, mean that
increasing numbers of hospitals are moving to digital.
21d. True
At a dose of 2 mGy the risk of inducing fatal cancer in the 50–65-yearold
age group is 1 in 50 000. In screening programmes the ALARP principle is
especially important.
21e. True
Most mammography exposures are at the lower end of this range.

22. With linear tomography:

a. Blurring is deliberately introduced into the image through movement
b. The cut plane slice is centred at the pivot height
 c. The slice thickness is increased by increasing the angle of movement of
the tube and plate
d. Zonography techniques image a very narrow slice thickness
e. Contrast is typically lower in linear tomography compared to conventional
radiography because of the blurring of overlying tissues spread over the
image
Answers

22a. True __
The movement of the plate and tube causes the shadow of objects above and
below the selected slice to move across the plate and become blurred,
leaving only the image of objects within the selected slice in focus.
22b. True
To adjust the level of the cut plane slice, the pivot height is adjusted up or
down.
22c. False
The slice thickness is increased by reducing the angle of movement. If the
angle of movement was zero then a conventional radiograph would be taken
with all structures within the slice thickness.
22d. False
Zonography uses a small angle to take a thick slice to image an entire organ
or when contrast is expected to be low.
22e. True
This blurring combined with increased attenuation of the beam passing
obliquely through the patient leads to higher doses being needed compared
with a conventional radiograph.
23. Concerning dual energy radiography:
a. Images are taken in rapid succession, alternating between a high tube
current and a low tube current to allow the formation of a subtracted image
that maximizes tissue contrast
b. For a given mA, soft tissue contrast will be increased by using a lower kV
X-ray beam
c. Subtracting a low kV image from a high kV image will improve soft
tissue contrast and minimize the visualization of bone
d. The detection of a calcified lung nodule could be improved by subtracting
the low kV image from the high kV image
e. Dual energy digital subtraction angiography (otherwise known as
DE DSA) is performed after an intra-arterial or intravenous injection of
iodinated contrast medium
Answers

23a. False ____

Dual energy radiography uses a composite of two images obtained with
different tube voltages. They can then be subtracted from one another to
form an image with high soft tissue contrast (subtract low kV from high kV)
or an image with high bone contrast (subtract high kV from low kV).
23b. True
A low kV beam will have higher contrast.
23c. True
Subtracting the high kV image from the low kV image will improve contrast
of the bony structures.
23d. False
Subtraction of the high kV image from the low kV image will improve
detection of calcified structures
23e. False
Contrast enhanced angiography uses a digital subtraction technique, where
the pre-injection image is subtracted from the post-injection image to show
only the contrast filled vessels. DSA stands for digital subtraction
angiography.
24. Regarding the interaction of radiation with the body:
A Photons of energy of 40keV react with soft tissues of the body,
predominantly by the Compton reaction.
B. Bone has a higher effective atomic number than soft tissue for a
diagnostic energy range.
C. For a given energy and medium in the diagnostic range the actual linear
attenuation coefficient is alway s higher than the Compton linear attenuation
coefficient.
D. The units of the mass energy absorption coefficient are centimetres
(squared)/kg.
E. The linear attenuation coefficient is the mass attenuation coefficient
divided by the density.
Answers

24. A True: Compton reaction is proportionally higher for soft tissue at

40keV.
B. True: The approximate mean atomic number of bone is 13.8 and of soft
tissue is 7.4.
C. True.
D. True.
E. False: MAC = LAC/density.

25. Regarding x-ray production:

A Beam quality depends on kV and voltage waveform.
B. Beam intensity depends on the atomic number of the target, tube current,
kV, and kV waveform.
C. Characteristic radiation constitutes a steadily increasing proportion of the
total with increasing kV.
D. No characteristic K shell radiation is produced from a Tungsten target at
kV p
E. After 2.5mm of aluminium filtration, the peak intensity of an x-ray beam
occurs about
 1/3 of the maximum kVp.
Answers

25. A. True: Beam quality = kV p + HVL.

B. True: Beam intensity is the energy fluence rate. It is the total amount of
energy per unit area passing through a cross section per unit time. It depends
on tube current, atomic number and is inversely proportional to the square of
the distance from a point source.
C. False.
D. True.
E. True.

26. Regarding attenuation for an x-ray beam:

A. For a monochromatic beam attenuation is exponential.
B. The amount of attenuation increases as electron density increases.
C. Throughout the range of 20-1 OOkeV a greater proportion of interactions
are photoelectric for soft tissue as compared to bone.
D. The unit of mass attenuation coefficient (MAC) is grams per cm squared.
E. The half value thickness is the thickness of a substance that will reduce
the intensity of a beam by 50%.
Answers

26. A. True: Assuming the x-ray beam is traversing a homogenous medium.

B. True: As electron density increases, more photons are attenuated.
C. False: Photoelectric interactions occur more for bone than soft tissue
between 20 and 1OO keV.
D. False: The units of MAC are centimetres (squared)/kg.
E. True.

27. The mass attenuation coefficient:

A Is defined as the linear attenuation coefficient (LAC) divided by the
density.
B. Is affected by the atomic number.
C. Is directly proportional to the half value layer (HV L).
D. Is inversely proportional to the radiation energy.
 E. Depends on the type of radiation interaction.
Answers

27. A. True: MAC= LAC/density.

B. True: MAC is not affected by density. It is affected only by atomic
number and photon energy.
C. False: HVL = 0.69/LAC and since LAC is proportional to MAC then
MAC is inversely proportional to HVL.
D. False: This is only the case for elastic scattering (all energies) and
Compton interactions involving photons >100keV.
E. True.

28. Concerning the Compton effect:

A There is interaction between a free electron and a photon
B. For incident photons of equal energy, more energy is lost from the photon
as the scatter angle increases.
C. High energy radiation undergoes more scattering events than lower
energy radiation.
D. The amount of scattering that occurs depends on the electron density of
the scattering material.
E. The larger the angle through which the photon is scattered, the more
energy it loses.
Answers

28. A True.
B. True.
C. True.
D. True.
E. True: As the angle of scatter of a photon increases, more energy is lost
from the photon.

29. Compton interactions tend to reduce the contrast in the image because:
A The mean photon energy is reduced.
B. The recoil electrons affect the image.
C. The photon undergoes a change in direction.
 D. Attenuation of the beam is increased.
E. Compton interactions in the screen reduce contrast.
Answers

29. A False.
B. False.
c. True.
D. False.
E. False.

30. Scattered radiation reaching the film would be expected to be reduced by:
A A high tube kV.
B. A moving grid.
C. Coning.
D. Using tubes with higher heat rating.
E. Placing a thin sheet of zinc on the film cassette.
Answers

30. A False: High kV increases scatter production.

B. True: A moving grid prevents some scatter and some primary radiation
from reaching the film.
C. True.
D. False: This does not change the amount of scatter reaching the film.
E. True: All radiation is attenuated more therefore less scatter reaches the
film as the zinc sheet is between the scatter and the film.

31. Concerning anti-scatter grids:

A With a parallel grid, cut-off limits the maximum field size.
B. With a focused grid, cut-off limits the range of focus to film distance.
C. A linear grid reduces contrast in the direction perpendicular to the lead
strips.
D. Use of a grid may increase patient dose by a factor of 4.
E. Grid lines in an image occur only if a stationary grid is used.
Answers
 31. A True.
B. True.
C. False.
D. True.
E. False: Grid lines can occur with a moving grid as it is momentarily
stationary as it changes direction.

32. In the use of grids:

A The interspaces may be filled with aluminium.
B. The grid ratio is defined as the ratio between the height of the lead strips
and the distance between them.
C. The interspaces are usually much thicker than the lead strips.
D. In the linear grid it may be possible for the x-ray tube to be angled
without the effect of 'grid cut-off'.
E. A crossed grid is made of two superimposed linear grids having different
focusing distances.
Answers

32. A True: Usual interspace materials are plastic, carbon fibre, or

aluminium.
B. True.
C. True.
D. True.
E. False:A crossed grid is two stationary grids superimposed with their grid
lines at right angles to each other.T he radiation must pass though a tunnel
rather than just a channel.
Crossed grids require higher exposure and careful centring. If the grids are
not at right angles an artefact called Moire fringes may be visualized on the
film.
32. Use of a grid normally leads to:
A Reduced scatter dose to the patient.
B. An increase in the exposure latitude of the film screen combination.
C. An increase in the exposure to the patient.
D. A higher mean energy of the beam reaching the film.
E. A reduction of scatter radiation reaching the film.
Answers

33. A False: The patient gets the same or more scatter due to the higher dose
needed when using a grid.
B. False: This is inherent to the film screen.
C. True: More x-rays are needed to obtain the same film density when a grid
sits between the film and the patient.
D. True: The beam becomes more penetrating as lower energy radiation
cannot reach the film.
E. True.

34. A focused grid:

A May cause radiation cut-off at large field sizes.
B. Should be used within a defined range of focus to film distance.
C. Requires an increase in patient dose to achieve the same film density as
an exposure without a grid.
D. Reduces geometric distortion of the image.
E. Improves contrast by reducing the amount of scattered radiation reaching
the film.
Answers

34. A False.
B. True.
c. True.
D. False.
E. True.

35. X-ray exposure to the patient may be reduced by:

 A Adding a 2mm aluminium filter to the beam.
B. Using a higher kVp.
C. Reducing the x-ray target-object distance.
D. Using rare earth screens.
E. Using a Potter-Bucky grid.
Answers

35. A True: This removes low energy photons which contribute to dose but
not to the image.
B. True: This is a tricky question. It requires you to understand that kVp and
mAs are intrinsically linked. It is usually assumed that when the kVp is
increased that the mAs is reduced and vice versa.This will often not be
stated in the question. So as kVp increases, mAs concomitantly decreases.
C. False: This increases dose to the patient.
D. True: Rare earth screens are more efficient that calcium tungstate,
therefore less x-rays are needed for the same image. The downside of this is
that noise is increased as fewer photons contribute to the image.
E. False: A Potter-Bucky grid is the term used to describe the moving grid
assembly.

36. Secondar y radiation grids:

A Usual grid ratio is 4:1-16:1.
B. As grid height increases, resolution of the image improves.
C. Grid factor is the ratio of incident radiation to transmitted radiation.
D. They absorb both primary and secondary radiation.
E. Grid ratio is the ability of the grid to stop primary radiation.
Answers

36. A True.
B. True: As grid height increases, more scattered radiation is stopped and
resolution improves. However, primary radiation is also stopped and so a
higher dose is incurred.
C. False: Grid factor is the ratio of exposure needed with a grid/exposure
needed without a grid. The usual ratio is 2-6.
D. True.
 E. False: This is primary transmission.

37. The focal spot of the x-ray tube:

A Is the cause of the penumbra on the image.
B. Focal spot motion causes motion unsharpness.
C. Causes absorption unsharpness.
D. Emits radiation of uniform intensity across its face.
E. Significantly influences the degree of magnification of objects about the
size of the focal spot.
Answers

37. A True: The penumbra is a consequence of the focal spot. The penumbra
is the zone of unsharpness that represents the area at which the margins
caused by many point sources of x-rays in the focal spot overlap.
B. True: Any motion of the x-ray tube components or patient contributes to
motion
unsharpness.
C. False: Absorption unsharpness is caused by attenuation around the object
being imaged - not the focal spot.
D. False: Due to the anode heel effect, the intensity of radiation varies across
the face of the focal spot.
E. True.

38. Regarding the focal spot:

A Its size increases with an increase in the tube current.
B. Its resolving capacity can be measured by pinhole imaging.
C. Its size increases with increased kVp.
D. The focal spot is shorter when measured at the cathode end than at the
anode end.
E. A focal spot has improved resolving power if it has a centrally peaked
radiation intensity distribution.
Answers

38. A True: Blooming (an increase in focal spot size) occurs when there is
an increase in mA or a low kV, especially noticeable with small focal spots.
 B. False: Resolution is measured with a star test pattern. Focal spot size is
measured with pinhole imaging.
C. False: This has no impact on the focal spot size.
D. False.
E. True.

39. The effective focal spot is governed by:

A The target angle.
B. The target size.
C. The line focus principle.
D. The filament size.
E. The applied kV.
Answers

39. A True.
B. False.
c. True.
D. True.
E. True.

40. Concerning the 'air-gap' technique:

A Scatter is removed from the beam.
B. An air gap of more than 30cm is needed.
C. This technique is equivalent to using a grid, but a higher patient dose is
needed.
D. Grids are used in preference to an air-gap technique when imaging
paediatric patients.
E. An air gap requires increased patient dose.
Answers

40. A. False: Scatter is not removed. The scatter that misses the film does
not contribute to the image but scatter which does not lie obliquely
contributes to the image.
 B. True: With a gap of less than 30cm, too much scatter reaches the film to
be a valued technique.
C. False: Grids require a higher patient dose than air gap.
D. False: Grids are not used on paediatric patients due to the need for a
higher exposure.
E. True.

41. Regarding tomography:

A The x-ray tube and cassette move in opposite directions.
B. A large swing angle gives a thicker slice.
C. Blurring is used as an advantage.
D. This technique is often used in intravenous urography.
E. Increasing focus-film distance increases slice thickness.
Answers

41. A True: The x-ray tube and the cassette move in a fixed arc in opposite
directions relative to each other; but centred around the object of interest.
B. False: A large swing angle produces a thinner slice.
C. True: Peripherally, tissues are blurred with the object of interest in focus.
However this reduces contrast.
D. True.
E. True.

42. In tomography:
A The contrast is dependent on the slice thickness.
B. Only structures at right angles to the film appear sharp.
C. Tomography is most useful when imaging structures with low inherent
contrast.
D. Image unsharpness is unaffected by the use of tomography.
E. Patient dose is higher than in conventional radiography.
Answers

42. A. True.
 B. False: Structures at right angles appear more blurred than those parallel to
the film.
C. False: It is most useful when imaging structures with high inherent
contrast.
D. False.
E. True

43. When using a narrow angle in tomography:

A The section thickness increases.
B. Tissue contrast is reduced.
C. The blurring of structures outside the focal plane is increased.
D. T he unsharpness within the focal plane is increased.
E. The tendency for phantom image formation increases.
Answers

43 A. True.
B. False: T issue contrast is enhanced. Narrow angle tomography is
preferred when imaging tissue of low inherent contrast.
C. False: Decreased.
D. False: Decreased.
E. True: This can be compensated for by using multidirectional tomography.

44. In an x-ray tube, a rotating anode:

A Results in a larger focal spot.
B. Increases the maximum tube rating.
C. Allows larger exposures to be made when compared with a stationary
anode.
D. Reduces heat input to the x-ray tube.
E. Is constructed from molybdenum with a tungsten target.
Answers

44. A. False: Rotating the anode makes no difference to the size of the focal
spot.
B. True: Heat is spread over the track of the rotating anode. lt can withstand
much larger exposures without focal spot damage.
 C. True: A stationary anode allows only slow heat removal by conduction,
restricting the maximum exposures that can be made. Stationary anode tubes
are only used now for intra-oral dental sets and some mobile units.
D. False.
E. False: The anode can be made from rhodium and the target from both
molybedenum or rhodium in mammography.

45. In a rotating anode x-ray tube:

A The anode stem is made of tungsten.
B. The effective focal spot size depends on the anode angle.
C. Heat is removed from the anode mainly by thermal conduction.
D. Heat is removed more efficiently when a low current is used.
E. The anode heel effect occurs in a direction parallel to the anode-cathode
axis.
Answers

45. A. False: It is made of moly bdenum which is a poor thermal conductor.

B. True.
C. False: Heat is lost mainly by radiation. It cannot be removed by
convection as the rotating anode lies within a vacuum.
D. False: If a high current is used, heat is removed more efficiently.
E. True.

46. Filtration of the x-ray beam:

A. In the patient is known as inherent filtration.
B. Tends to increase tissue contrast.
C. Aluminium is more efficient than copper for filtering off higher energy
radiation.
D. Would be expected to decrease the maximum photon energy.
E. Helps to decrease the amount of loading on the x-ray tube.
Answers

46. A. False: Inherent filtration is the absorption of x-ray s within the x-ray
tube.
 B. False: Filtration increases the mean energy of the beam therefore
decreasing tissue contrast.
C. False: Aluminium atomic no is 13 and copper is 29 so copper attenuates
x-ray s more by photoelectric effect.
D. False: Maximum photon energy stay s the same - filtration preferentially
filters lower energy photons that results in a higher mean energy.
E. False: Filtration increases the loading on the tube because it increases the
mean photon energy, so giving higher output intensity.

47. Inherent filtration:

A. The glass envelope is responsible for most of it.
B. It varies approximately between 0.5 and 1 mm of aluminium equivalent.
C. D ecreases tissue contrast.
D. Bery llium has an atomic number of less than 10.
E. It includes the oil surrounding the tube.
Answers

47. A True: Inherent filtration is the combined filtration of the window of

the tube housing, the insulating oil, the glass insert and the target material
itself.
B. True.
C. True.
D. True: Bery llium has an atomic number of 4 and is used where inherent
filtration must be minimized, e.g. in mammography.
E. True.

48. In the x-ray tube:

A. The effective focal spot used in f\uoroscopy is usually less than 1 mm.
B. The intensity of the x-ray beam is greatest when perpendicular to the
incident electron beam.
C. Rotating anodes help in heat dissipation.
D. A tungsten-rhenium alloy does not roughen with use as much as a pure
tungsten anode.
E. The thermal rating of the tube increases as the kV is increased.
Answers

48. A True: In fluoroscopy the effective focal spot is usually 0.6mm (actual
focal spot can vary up to 50% from manufacturers' specifications).
B. True: This is where the beam is most useful.
C. True: Rotating anodes increase the area over which heat is produced so
helping to dissipate heat.
D. True: Rhenium is added to prevent cracking of the anode.
E. False.

49. The maximum photon energy in the spectrum of x-rays from an x-ray set
is influenced by:
A. The peak tube potential (kV).
B. Filtration.
C. Tube current (mA).
D. Target material.
E. The tube potential waveform.
Answers

49. A True.
B. False.
c. False.
D. False.
E. False.

50. If on taking an x-ray, the exposure (mAs) is set to keep the film density
constant, then:
A. An increase in tube potential (kV) will reduce the effective dose to the
patient.
B. Using a faster film screen combination will reduce the effective dose to
the patient.
C. Selecting a smaller focal spot will not affect the patient dose.
D. Increasing the x-ray field size will increase effective dose to the patient.
 E. Increasing the exposure time might result in increased patient dose.

Answers

50. A True: As mAs decreases.

B. True: As mAs must decrease to achieve the same film density.
C. True.
D. True.
E. True.

51. The thermal rating of an x-ray tube used in diagnostic radiology:

A. Is limited by the maximum allowable filament current at high kV.
B. ls greater when operated at full-wave rectification compared to half-wave
at an exposure of 0.1 sec.
C. Is influenced by anode angle.
D. Increases if the speed of rotation decreases.
E. Is, with respect to multiple exposures, dependent on the weight of the
anode.
Answers

51. A False.
B. False.
c. True.
D. False.
E. True.

52. Regarding x-ray tube ratings:

A. Only thermal ratings are important.
B. During screening, the heat capacity of the tube housing limits the
maximum tube current at a given kVp.
C. At very short exposures, three phase rectified x-ray tubes are rated higher
than full-wave rectified tubes.
D. When multiple short exposures are taken, more heat may arise from the
anode motor than from x-ray production.
 E. A rotating anode has improved efficiency of heat production compared
with a stationary anode.
Answers

52. A False: Electrical ratings are important too.

B. False: The anode heat storage capacity is the limiting factor.The tube
housing heat capacity is much higher.
C. True.
D. True.
E. False: Regardless of the ty pe of anode, the efficiency of heat production
is largely similar - with over 99% of energy lost as heat.

53. The heat rating of an x-ray tube:

A. Decreases as the kV is increased.
B. Increases as exposure time is lengthened.
C. Is greater for a high speed anode.
D. Is greater for a stationary anode than for a rotating one.
E. Increases with an increase in effective focal spot size.
Answers

53. A True: As kV increases, mAs is decreased. The higher the mAs used,
the more effective heat removal is.
B. False.
C. True.
D. False.
E. True.

54. Regarding subject contrast in radiography, which of the following are

correct?
a. It depends on the thickness of the structure being imaged
b. It depends on the linear attenuation coefficients of the structures being
imaged
c. It increases with the tube kV
 d. Contrast between low-atomic-number structures (e.g. fat and muscle) is
strongly affected by changes in the tube kV
e. Contrast between air and soft tissue is due to differences in their atomic
numbers
Answers

54. a. True. It is proportional to the thickness of the imaged object.

b. True. It is proportional to the difference between linear attenuation
coefficients of the tissues involved.
c. False. With increasing peak kV (kVp), the relative probability of the
Compton effect increases, which compromises contrast.
d. False. In the range of photon energies used in general radiography, the
contrast between low-atomic-number tissues is low and only minimally
dependent on kVp.
e. False. It is due to a large difference in density. The effective atomic
numbers of air and soft tissue are very similar.

55. Concerning radiographic contrast:

a. Attenuation of the X-ray beam depends upon the degree of
Bremsstrahlung in the tissue
b. Most structures on a chest radiograph exhibit good radiographic contrast
c. In principle, contrast media have the same effect on demonstrating
contrast between tissues as increasing the peak kV (kVp)
d. All contrast media attenuate X-rays to a higher degree than the tissue
e. Positive-contrast media should generally have high atomic numbers to
maximize the degree of photoelectric absorption
Answers

55. a. False. Attenuation is due to Compton scattering and photoelectric

absorption.
Bremsstrahlung relates to the production of X-rays.
b. True. This is due to the different attenuation properties of air, fat, soft
tissue and bone (the main four ‘radiographic densities’).
c. False. As they improve contrast, their effect is analogous to decreasing the
peak kV (kVp).
 d. False. Negative-contrast media (for example, air or carbon dioxide) are
radiolucent.
e. True.

56. Which of the following are correct for positive-contrast media?

a. They should ideally have an absorption edge just to the left of the major
part of the beam spectrum
b. Barium has a K-absorption edge of approximately 23 keV
c. Iodine has a lower atomic number than barium
d. Iodine most effectively attenuates photons with energies close to 37 keV
e. They may produce characteristic radiation
Answers

56. a. True.
b. False. This is the value for rhodium. Barium has an absorption edge of 37
keV.
c. True. The atomic numbers of iodine and barium are 53 and 56,
respectively.
d. False. As the K-absorption edge of iodine is 33 keV, it is most effective in
attenuating photons of this energy. The answer to this question would be true
for barium.
e. True. This happens when an electron within the K-shell is ejected and
replaced by an electron from another valence band.

57. Concerning magnification:

a. It occurs because X-rays converge on the object
b. Assuming a fixed focal spot position, it increases as the object is moved
nearer to the film
c. Assuming a fixed position of the object in relation to the focal spot, it
increases as the focus-to-film distance (FFD) is increased
d. If the object is in contact with the film, the magnification factor is 1
e. Minification of the image with film-screen radiography cannot occur
Answers
 57. a. False. It occurs because X-rays are divergent from their source.
b. False. This decreases magnification.
c. True. The object-to-film distance would increase.
d. True. In this case, there would be no magnification.
e. True.

58. Geometric unsharpness:

a. Occurs because X-ray photons are emitted from an area of finite size
rather than from a point source
b. Increases with focal spot size
c. Decreases with shortening of the object-to-film distance
d. Increases with shortening of the focus-to-film distance
e. Decreases towards the anode side of the image
Answers

58. a. True.
b. True. The larger the focal spot size, the larger the penumbra (image blur
around the edges of an object).
c. True. The closer the object to the detector, the less unsharpness.
d. True. The closer the focus to the film, the more geometric unsharpness. In
summary, geometric unsharpness depends on the focal spot size ( f ), object-
to-film distance (h) and focus-to-film distance (FFD) and is given by the

formula
e. True. This is because the projected focal spot decreases in size towards the
anode side.

59. Regarding movement (motion) unsharpness:

a. It can be reduced by immobilization
b. It can be reduced by using a short exposure time
c. It can be exaggerated by increasing the object-to-film distance
d. Increasing the focus-to-film distance always decreases movement
unsharpness
e. Shortening the exposure time to overcome the motion unsharpness may
contribute to increased geometric unsharpness
Answers

59. a. True. However, this may not always be possible (e.g. in case of
movement blur due to heart beating).
b. True.
c. True. In this case, the same amount of object movement will translate to a
larger distance on the film.
d. False. It may increase motion blur as it necessitates increased exposure
time.
e. True. This is because to expose the film in a shorter time, the tube current
needs to be increased, which may require selecting a larger focal spot. The
size of the focal spot may also increase with a higher tube current due to the
blooming effect.

60. Concerning the focal spot:

a. The area of the anode over which electrons are targeted is the actual focal
spot
b. The size of the effective focal spot is the same as the actual focal spot
c. The anode angle is the angle between the central X-ray beam and the
target face
d. The value of the anode angle is usually in the range of 7–30 deg
e. Increasing the anode angle increases the actual focal spot size
Answers

60. a. True.
b. False. The effective focal spot is the area of the actual focal spot viewed
from the film. Due to anode angulation, it is smaller than the actual focal
spot.
c. True.
d. False. It is usually 7–20 deg.
e. True.

61. Concerning the focal spot:

a. A larger actual focal spot allows greater tube currents
 b. Increasing the anode angle increases the maximum permissible exposure
factors that can be used
c. A typical size of focal spot in general radiography is 1 mm
d. Focal spot size has no effect on contrast
e. A larger focal spot size increases the amount of scatter
Answers

61. a. True.
b. True. Increasing the anode angle increases the size of the actual focal spot
and so a greater tube current or kVp may be used.
c. True.
d. True.
e. False. It does not affect scatter.

62. Concerning the focal spot:

a. Its size may be estimated using a slit camera
b. Its size may be estimated using a star test pattern
c. A smaller anode angle reduces the size of the effective focal spot
d. A larger anode angle is useful for general radiography
e. The size of the actual focal spot is partly determined by the length of the
cathode filament
Answers

62. a. True. A slit camera consists of a metal plate with a slit positioned
between the tube and the image receptor. One dimension of the focal spot
can be calculated from magnification of the slit image. This is then repeated
for the other dimension with the slit perpendicular to its original position.
b. True. This involves a test object with markings at a set distance apart with
which an image is produced of a certain magnification. The degree of
blurring of the markings in the image can be used to estimate focal spot size,
as it is greater with a larger focal spot.
c. True.
d. True. This allows greater tube loading and higher output, which is often
necessary when imaging larger parts of the body. It also increases the size of
the field coverage at short focal spot-to-image distances.
 e. True. It is also determined by the width of the focusing cup at the cathode.

63. The heel effect:

a. Is due to attenuation of electrons in the target material
b. Is greater on the cathode side of the X-ray field
c. Is more pronounced at small anode angles
d. Is more noticeable at high peak kV (kVp)
e. Results in higher mean energy spectrum of the beam on the anode side
compared to the cathode side
Answers

63. a. False. It is due to attenuation of X-ray photons produced by the target

material.
b. False. Due to anode angulation, photons emitted towards the anode side of
the field need to penetrate a larger thickness of the anode material and
therefore undergo more attenuation.
c. True. The steeper the target, the larger the thickness of the target material
that needs to be penetrated on the anode side.
d. False. It is more noticeable at low kVp, as the photons are less penetrating
and the differences in attenuation on the cathode and anode sides are more
pronounced.
e. True. Because photons penetrating through the target material in addition
to attenuation also undergo filtration.

64. Regarding the heel effect:

a. It is more pronounced in worn-out anodes with a rugged surface
b. It is less pronounced in tubes with rotating compared with stationary
anodes
c. For a given film size, it is more noticeable on images acquired with a long
focus-to-film distance
d. In mammography, the anode side of the tube should be directed towards
the chest wall
e. It is useful in spine radiographs
Answers
 64. a. True. The electrons penetrate deeper into the anode material and the
photons produced have a greater distance to travel through it.
b. False. Anode rotation does not directly affect the heel effect. However,
the heel effect is of less significance in stationary anodes tubes as they tend
to have larger anode angles (due to thermal factors), and the field uniformity
is not as critical in the applications they are used in.
c. False. With a long focus-to-film distance, only the central, more uniform
part of the beam is used to produce the image and the heel effect is less
noticeable.
d. False. The anode side (with a lower intensity of the beam due to the heel
effect) should point away from the chest wall (where the thickness of breast
tissue is less).
e. True. It may be used to compensate for varying patient thickness along the
cranio-caudal axis. For example, antero-posterior (AP) images of the
thoracic spine are normally more penetrated (darker) towards the upper
vertebrae.
With the anode facing cranially, more uniform images can be obtained.

65. Regarding X-ray tube operation:

a. Peak kV (kVp) and mA may be varied independently of one another
b. For a given anode, the focal spot size cannot be varied
c. Exposure settings may be set automatically by the system
d. Automatic exposure control (AEC) is usually used
e. mA and exposure time are usually adjusted simultaneously
Answers
65. a. True.
b. False. This may be achieved by choosing a different filament length (there
are usually two). Some anode discs may also have bevels at different
inclinations allowing the choice of a different anode angle.
c. True. This may be achieved automatically by anatomically programmed
radiography (APR), which will set the kVp/mA/exposure time depending on
the particular projection.
d. True. AEC uses a radiation detector (usually an ionization chamber)
placed in close proximity to the image plate, terminating exposure when a
sufficient quantity of radiation has reached the film. This is especially
 important in computed/digital radiography where the detector has a large
latitude, and the choice of excessive parameters does not result in obvious
overexposure.
e. True. They are usually adjusted as a single parameter (mAs).

66. Which of the following are true about the quality and quantity of the X-
ray beam?
a. The quality describes the number of photons in the X-ray beam
b. The quantity determines the penetrability of the X-ray beam
c. The quantity is inversely proportional to the tube current
d. The quantity is directly proportional to the tube voltage
e. The quantity is dependent on the choice of target material in the anode
Answers

66. a. False. This is the quantity.

b. False. X-ray beam penetrability is dependent on beam quality. An X-ray
beam containing higher energy photons is more penetrating.
c. False. It is directly proportional.
d. False. In the range of tube voltages used in general radiography, it is
approximately proportional to the square of peak kV (kVp).
e. True. The amount of Bremsstrahlung radiation produced in higher-atomic-
number targets is greater.

67. Concerning exposure controls:

a. Automatic exposure control (AEC) can be varied to adjust the optical
density of the film
b. A faulty AEC detector will usually result in significant overexposure of
the patient
c. AEC is more likely to ensure the correct exposure when used with
collimation
d. AEC typically uses five ionization chambers
e. All ionization chambers must be used simultaneously
Answers

67. a. True. The operator can adjust the AEC to produce an image of a
certain optical density, known as the density setting.
b. False. This should be prevented by a back-up timer, which terminates the
exposure if the AEC fails to do so, usually when 150% of expected manual
exposure is reached.
c. True.
d. False. There are usually three chambers covering different areas of the
film.
e. False. The operator can select which chambers to use depending on the
projection.

68. Regarding collimation:

a. It allows the operator to adjust the filtration of the X-ray beam
b. It employs a light beam diaphragm
c. The collimators are constructed of material that is highly attenuating to X-
rays
d. It reduces scatter
e. It does not affect the effective dose to the patient
Answers

68. a. False. It allows adjustment of the beam size. It has no effect on

filtration.
b. True. This is a light source that projects as though it originated from the
X-ray focus, allowing the operator to see the position of the beam projected
onto the patient.
c. True.
d. True. Less tissue is irradiated by directing the X-ray beam onto a smaller
target area.
e. False. It decreases the volume of tissue irradiated and the radiation dose.

69. Regarding the X-ray tube anode:

a. It is the site of thermionic emission
b. Tungsten is a suitable target material
 c. Electrons striking the anode mostly convert their energy into X-ray
photons
d. It is usually rotating
e. The anode material used in mammography is the same as in general
radiology
Answers

69. a. False. Thermionic emission occurs in the cathode, and the released
electrons are targeted on the anode target.
b. True. This is due to its high melting point and high atomic number (Z =
74), which increases the degree of Bremsstrahlung.
c. False. The energy of the electrons is mainly converted into heat, which is
why the anode must be able to tolerate a significant temperature rise. Less
than 1% is converted to X-ray photons.
d. True. The anode may be stationary or rotating. Rotating anodes are used
for better tolerance of the heat generated during the production of X-rays, as
the heat is spread over a larger area.
e. False. Rhodium (Z = 45) and molybdenum (Z = 42) are chosen due to the
useful energies of characteristic radiation.

70. Regarding the construction of a rotating anode X-ray tube:

a. The entire anode disc is usually made of tungsten
b. The anode stem is made of molybdenum to improve the conduction of
heat away from the anode disc
c. The rotor bearings are lubricated with a soft metal
d. The electric brushes of the X-ray tube motor are made of graphite
e. The filament assembly is aligned with the anode stem
Answers

70. a. False. It is usually made of molybdenum, in which the target annulus

(made of tungsten alloy) is embedded.
b. False. The opposite is true. Molybdenum has a low heat conductivity,
which slows the conduction of heat towards the rotor bearings, protecting
them from heat damage.
c. True. They are usually lubricated with silver powder.
 d. False. Induction motors are used. These are brushless.
e. False. The filament is offset towards the edge of the anode, in line with
the target annulus.

71. With regard to the cooling of a rotating anode X-ray tube:

a. Heat produced in the focal spot is transferred to the glass envelope by
convection.
b. Heat is transferred out of the tube housing into the atmosphere by
conduction
c. The anode assembly is blackened to improve radiation of heat
d. The major thermal limiting factor for single exposures is the heat capacity
of the focal spot area
e. In the case of continuous/repeated exposures, the major limiting factor is
the heat capacity of the anode disc and the tube housing
Answers

71. a. False. It is conducted to the anode disc and transfers to the glass
envelope by radiation. It cannot be transferred between the anode and glass
by convection as the tube is evacuated. Some heat is transferred via
conduction through the anode stem (this becomes the main process at lower
temperatures as heat radiation becomes less significant). From the glass, heat
is transferred to the insulating oil and the tube housing by convection.
b. False. It is transferred by radiation and convection.
c. True. Blackening substantially increases the emissivity coefficient.
d. True.
e. True.

72. Regarding the high-voltage supply to the X-ray tube:

a. In a self-rectified tube, X-rays are produced during both the positive and
the negative halves of the supplying voltage waveform
b. In a tube connected to a half-wave rectifying circuit, X-rays are produced
during both halves of the supplying voltage waveform
c. In a fully rectified one-phase circuit, the voltage across the tube is almost
constant
 d. A fully rectified three-phase supply provides more constant voltage
throughout the cycle than a one-phase supply
e. A tube supplied from a high-frequency generator requires less filtration in
comparison with that supplied from rectified circuits
Answers

73. a. False. In a self-rectified tube, electrons travel towards the anode only
during the positive half of the waveform. During the negative half of the
cycle, the filament has positive potential and does not emit electrons; at high
tube currents, the anode may reach temperatures sufficient for thermionic
emission and electrons may flow towards the filament, destroying the tube.
b. False. In a half-rectified circuit, the negative half of the voltage waveform
is eliminated. As potential across the tube during this period of the cycle is
zero, there is no electron flow and no X-ray production.
c. False. In a fully rectified circuit, the negative half of the cycle is ‘flipped’
into positive. Therefore, in both halves of the cycle, the filament and the
target have the correct polarity to produce X-rays. However, the voltage
across the tube fluctuates from zero to maximum, and the mean energy of
the photons produced is relatively low.
d. True. With three overlapping fully rectified waveforms, the fluctuations in
the tube voltage (ripple) are greatly diminished. The voltage across the tube
never falls to zero and the efficiency of X-ray production is higher, as is the
mean photon energy. High-frequency generators provide yet further
improvements with a practically constant potential.
e. True. More filtration is needed to eliminate photons with lower energies
produced by the latter.

74. Regarding factors affecting X-ray emission:

a. The tube voltage affects the maximum energy of Bremsstrahlung radiation
b. Due to inherent tube filtration, the maximum energy of photons measured
in keV is slightly lower than the tube potential in kV
c. Beam filtration affects both the quantity and quality of the X-ray beam
d. Increasing peak kV (kVp) increases the quantity and quality of the emitted
X-ray beam
 e. Increasing the tube current decreases the half-value layer (HVL) of the
beam
Answers

74. a. True.
b. False. Filtration does not affect the maximum energy of the beam
spectrum, which is always equal in keV to the tube potential in kV.
c. True. Filtration selectively removes the lower energy photons so it reduces
the quantity. It shifts the mean energy of the remaining photons to a higher
level, so it increases the beam quality.
d. True.
e. False. The HVL depends on the quality of radiation (energy spectrum),
which is not changed by altering mA.
75. X-ray exposure ratings:
a. Determine the operational limits of the X-ray equipment
b. May be illustrated graphically
c. Are independent of focal spot size
d. Are dependent on the anode rotation speed
e. Are the same for single and repeated exposures
Answers

75. a. True. They describe the maximal operational settings that are
permissible without damage to the anode and tube housing.
b. True. There are rating charts that display curves showing the maximum
permissible mA depending on exposure time and peak kV (kVp) for a
particular X-ray tube and focal spot size.
c. False. The size of the focal spot has an influence on the tube current that
can safely be tolerated.
d. True.
e. False. Ratings for repeated exposures are lower as heat accumulation
needs to be taken into account.
76. Regarding patient dose in radiography:
a. The ratio of entrance surface dose (ESD) to exit dose is similar in most
radiographic examinations
 b. The film dose required to produce an image in film-screen radiography is
in the range of 0.2–0.5 µGy
c. Increasing mAs increases the exit dose and ESD proportionately
d. Increasing the tube kV increases the ratio of ESD to the exit dose
e. Increasing filtration reduces the ratio of ESD to the exit dose
Answers

76. a. False. Depending on examination type, this ratio may vary from 10
(for a PA chest X-ray) to over 5000 (in the case of a lateral lumbar spine
radiograph).
b. False. A dose of approximately 3 µGy is required.
c. True.
d. False. With increased kV, the X-ray beam is more penetrating and a lower
entrance dose is required to produce the same exit dose. In general, the
highest peak kV (kVp) producing acceptable image contrast should be used.
e. True. This is because increasing filtration makes the beam more
penetrating.

77. Patient dose in radiography can be reduced by:

a. Increasing the focus-to-film distance
b. Compression
c. Collimation
d. Using a secondary radiation grid
e. Using the air-gap technique
Answers

77. a. True. Even though increasing the distance necessitates the increase in
mAs it decreases the skin dose as the beam entering the patient is spread
over a larger surface area. It also decreases the dose to deeper tissues to a
lesser extent.
b. True. This is due to a reduction of the required exposure factors (less
tissue thickness to penetrate) and the amount of scattered radiation.
c. True.
 d. False. The exit dose needs to be increased by a factor equal to the Bucky
factor of the grid (the ratio of radiation incident on the grid to the transmitted
radiation) to obtain the same film exposure.
e. False. Use of an air gap requires a higher tube output and increases the
patient dose.

78. The amount of scattered radiation leaving the patient is decreased by:
a. Decreasing the tube kV
b. Reducing the field area by collimation
c. Compression of the patient
d. Using a radiation grid
e. Using the air-gap technique

78. a. True. There is less scatter in the forward direction and it is less
penetrating.
b. True. This reduces the amount of scatter produced.
c. True. This also reduces the amount of scatter produced.
d. False. A grid reduces the amount of scattered radiation reaching the
imager, but not the amount of scatter leaving the patient. As it necessitates
an increase in tube output, the grid may actually increase the amount of
scatter produced (and the patient’s dose).
e. False. This is based on the same principle as (d).

79. Increasing the focus-to-film distance while keeping the film exposure
constant:
a. Improves radiographic contrast
b. Reduces patient dose
c. Reduces magnification
d. Reduces geometric unsharpness
e. Improves field uniformity
Answers

79. a. False. It does not influence the radiographic contrast.

b. True.
c. True.
 d. True.
e. True.

80. Regarding the construction of a radiation grid:

a. It is made of 0.05–0.07 mm lead strips
b. The line density of a grid is usually 12–16 cm_1
c. The gaps between the lead strips are filled with air
d. The grid ratio is the ratio of the depth of the interspace channel divided by
its width
e. A typical grid ratio is 30:1–80:1

Answers

80. a. True.
b. False. The line density of a grid (number of lead strips per cm) is usually
30–80 cm–1 (typically 40).
c. False. Usually aluminium, carbon fibre or plastic are used as interspace
material.
d. True.
e. False. It is typically 8:1. High-ratio grids (12:1–16:1) are used with very
large fields and high peak kV (kVp).
81. Concerning radiation grids:
a. A parallel grid is focused at infinity
b. For a focused grid, the focusing range depends on the grid ratio
c. In the case of a crossed grid composed of two linear grids, the resulting
grid ratio is equal to the product of individual grid ratios
d. The contrast improvement factor of a typical grid is 2–4
e. Grids are generally not used in paediatric radiography
Answers

81. a. True. This means that if the X-ray tube was located at infinity, the
incident beam would be parallel to the lead strips and no primary radiation
would be lost. With a finite focus-to-film distance, the X-rays towards the
periphery of the beam strike the lead strips obliquely and are attenuated (grid
cut-off). This is more pronounced for high grid ratios (therefore parallel
 grids rarely have ratios higher than 6:1) and short tube-grid distances
(therefore parallel grids should not generally be used at distances of less than
150 cm).
b. True. In a focused grid, the lead strips are tilted progressively from the
centre to the edges, pointing in the direction of a point in space termed the
convergent point. If the focal point of the tube is in the convergent point,
there is no loss of primary radiation. In practice, there is a degree of latitude
with regard to focal point placement – it may be positioned within a range of
distances (focusing range) without significant loss of primary radiation. The
focusing range is wide for low-ratio grids and narrow for high-ratio grids
(the high-ratio grids therefore require more precise positioning).
c. False. The resulting ratio is the sum of the individual ratios.
d. True. This depends on the grid ratio and factors affecting the amount of
scatter produced (e.g. kVp, depth of the patient tissue and field size).
e. True. This is because the amount of scatter arising in a small patient is low
and the increase in dose caused by the grid would be highly undesirable.

82. Regarding dual-energy radiography:

a. It exploits spectral differences in X-ray attenuation by various tissues
b. It may be used to produce selective tissue images
c. It always requires two separate exposures
d. In dual-exposure systems for chest radiography, tube potentials of 60 and
120 kV are usually used
e. Dual-exposure systems are prone to misregistration artefacts
Answers

82. a. True. It is based on differences in the degree to which different tissues

attenuate high- and low-energy photons.
 b. True. By subtracting images obtained at high and low peak kV (kVp),
selective bone and soft tissue images can be obtained.
c. False. This is true for dual-exposure systems that obtain two radiographs
sequentially at different kVp. There are also single-exposure systems where
two image plates divided by a copper filter (‘sandwiched detectors’) are
simultaneously exposed, with the back detector receiving filtered, higher
energy photons.
d. True.
e. True. This is due to a slight (200 ms) time delay between the two
exposures.

89. Concerning dual-energy radiography:

a. Dual-exposure systems produce selective tissue images with a better
signal-to-noise ratio than single-exposure systems
b. It requires slightly lower radiation doses than conventional radiography
c. It is most commonly used in chest imaging
d. It helps detect calcium within soft tissue structures
e. Three images are typically produced for reporting
Answers

89. a. True.
b. False. A slightly higher radiation dose is required.
c. True.
d. True.
e. True. These are the unsubtracted image, the selective soft tissue image and
the selective bone image.

90. Regarding quality assurance in radiography:

a. The tube kV is tested using a dosimeter
b. Tube output is assessed with an ionization chamber or a solid-state
detector
c. For a given mAs, the output of the tube should be constant over the entire
voltage range
 d. Tube filtration is assessed by measuring the half-value layer (HVL)
e. Light beam diaphragm alignment should be checked yearly.
Answers

90. a. False. It is tested using a digital kV meter.

b. True.
c. False. In the range of 60–120 kV, tube output is proportional to the square
of the peak kV (kVp2). For lower kV (e.g. in mammography), output is
proportional to kVp3.
d. True.
e. False. It is usually tested every 1–2 months.