RPSGT practice test: 30 free polysomnography questions

A patient with suspected OSA asks what happens after a negative HSAT. Per AASM 2017, the RECOMMENDED next test is:

Mark a letter. The key, plus a line on every option, opens at once.

1. Home oximetry on its own

   Home oximetry on its own is not an accepted diagnostic test for OSA and misses events without desaturation.
2. An in-lab polysomnogram

   When a single HSAT is negative but OSA is still suspected, the 2017 AASM guideline calls for an in-lab polysomnogram, which records sleep and catches what home testing can miss.
3. An empiric APAP trial

   An empiric APAP trial starts treatment without a diagnosis, which the guideline requires beforehand.
4. A repeat HSAT next week

   A repeat HSAT next week repeats the test that already failed to show the disorder; the guideline prefers PSG over a second home study.

Which statement correctly distinguishes RLS from PLMD?

1. PLMD is diagnosed by history; RLS needs PSG

   This reverses the two: PLMD is the disorder that cannot be diagnosed without a sleep study.
2. Both require a PLM index above 15

   Many people with RLS have few PLMs, and the RLS criteria contain no PSG index at all.
3. PLMD is often diagnosed together with RLS

   PLMD is not diagnosed when RLS is present, because RLS already explains the limb movements.
4. RLS is diagnosed by history; PLMD needs PSG

   RLS rests on the patient's description of an evening urge to move the legs, while PLMD requires a PSG with an elevated PLM index and a sleep complaint.

A brief, sudden jerk of the whole body at sleep onset, sometimes with a sense of falling, is:

1. A hypnic jerk

   A single brief jerk as sleep begins, often with a falling sensation, is a sleep start, a normal event.
2. A periodic limb movement

   A periodic limb movement is one of a series of repeated leg movements during sleep, not one whole-body jerk.
3. A myoclonic seizure

   A myoclonic seizure needs epileptiform activity and is not tied to the moment of falling asleep with a falling sensation.
4. Cataplexy

   Cataplexy is sudden loss of muscle tone during wakefulness, usually set off by emotion, not a jerk at sleep onset.

A patient tapes over the small holes on the CPAP mask to stop the hissing noise. The technologist explains that these vent holes:

1. Lower the pressure reaching the airway

   The blower compensates for vent flow to hold the set pressure, so the vent is not a pressure-relief device.
2. Release excess humidity from the mask

   Excess humidity and rainout are managed with humidifier settings and heated tubing; the vent holes exist for exhaled gas.
3. Muffle the noise of the blower

   The hiss comes from the vent itself, and the fix for noise is a diffuser vent or another mask, never blocking it.
4. Wash exhaled air out of the mask

   The vent is the intentional leak; steady flow through it carries exhaled CO2 away, so taping it over leads to rebreathing.

Which scale rates how sleepy a patient feels at one moment, such as just before an MSLT nap?

1. Epworth Sleepiness Scale

   The Epworth scale rates the usual chance of dozing in everyday situations, a trait over recent weeks rather than a moment.
2. Stanford Sleepiness Scale

   The Stanford scale asks how sleepy the person feels right now, so it can be given before each nap.
3. Insomnia Severity Index

   The ISI rates insomnia symptoms over the last two weeks, not momentary sleepiness.
4. Pittsburgh Sleep Quality Index

   The PSQI looks back over a month at sleep quality and habits.

A patient with RLS on pramipexole now has symptoms starting earlier in the day and spreading to the arms. This is:

1. Drug tolerance

   Tolerance is a fading effect at the same dose; it does not move symptoms earlier or into new body parts.
2. Augmentation

   Symptoms that start earlier in the day, grow stronger and spread to the arms on a dopamine agonist define augmentation.
3. End-of-dose rebound

   Rebound is symptoms returning in the early morning as a dose wears off, without earlier onset or spread.
4. Akathisia

   Akathisia is a general inner restlessness from dopamine-blocking drugs, without the evening, leg-centered pattern of RLS.

By EEG convention, an upward deflection in F4-M1 means F4 is:

1. Positive relative to M1

   A positive input 1 deflects the pen downward, the opposite of what is shown.
2. Equal in potential to M1

   Equal potentials at both inputs produce a flat trace, not a deflection.
3. Grounded through M1

   The ground is a separate electrode; M1 is the reference input and does not ground the channel.
4. Negative relative to M1

   By convention a trace deflects upward when input 1, here F4, is negative relative to input 2.

Rhythmic bursts of high-frequency activity, about 1 s each and repeated in sequence, appear in the chin lead and spill into nearby scalp and eye leads. What is the MOST likely cause?

1. Electrode popping

   A pop is a single steep spike limited to the channels that share one faulty electrode, not repeated bursts.
2. Teeth grinding

   Teeth grinding (bruxism) appears as repeated bursts of muscle activity in the chin lead that spill into the scalp and eye leads.
3. 60 Hz interference

   Mains interference is a steady, continuous fuzz, not bursts that start and stop.
4. Sweat artifact

   Sweat produces a slow, drifting baseline sway, not high-frequency bursts.

Leg EMG for periodic limb movements is recorded from which muscle?

1. Gastrocnemius

   The gastrocnemius is a calf plantar flexor, so it misses the dorsiflexion that defines most PLMs.
2. Quadriceps femoris

   The quadriceps extends the knee and does not capture the typical dorsiflexion movement.
3. Soleus

   The soleus plantar flexes the ankle, the opposite direction of a periodic limb movement.
4. Anterior tibialis

   PLMs are mostly ankle and toe dorsiflexion, which the anterior tibialis produces, so both legs are recorded there.

The preauricular-to-preauricular distance through Cz is 34 cm. How far from the left preauricular point is C3?

1. 3.4 cm

   3.4 cm is the first 10%, which marks T3, not C3.
2. 6.8 cm

   6.8 cm is only 20% of 34 cm, which forgets the first 10% step from the preauricular point to T3.
3. 10.2 cm

   C3 lies 30% of the coronal distance from the preauricular point, 10% to T3 plus 20% more: 0.30 × 34 = 10.2 cm.
4. 17.0 cm

   Half of 34 cm locates Cz at the vertex, not C3.

Adding an oronasal thermal sensor to a type III HSAT that already has nasal pressure MAINLY:

1. Improves hypopnea detection

   Nasal pressure is the better hypopnea sensor and is already in place; the thermal sensor adds little there.
2. Improves apnea detection

   Nasal pressure can read mouth breathing as absent flow, so a thermal sensor makes apnea identification more reliable.
3. Is required for adequacy

   A thermal sensor is not required for adequacy: a home study can rely on nasal pressure, effort and oximetry.
4. Allows arousal scoring

   Arousal scoring needs EEG, which a type III device does not record, so a thermal sensor cannot allow it.

Which signals are required to stage sleep on a PSG?

1. EEG, ECG and leg EMG

   ECG and leg EMG record heart rhythm and limb movements, neither of which defines a stage.
2. EEG and EOG only

   EEG and EOG only leaves out chin EMG, the tone drop that marks R.
3. EEG, EOG and chin EMG

   Staging needs brain waves, eye movements and chin muscle tone; without the chin channel R cannot be separated from wake or N1.
4. EEG, airflow and SpO2

   Airflow and oxygen saturation score breathing events, not sleep stages.

A slow wave in O2-M1 rises and falls with each breath while the patient lies supine on the occipital electrode. This is:

1. Alpha rhythm

   Alpha is an 8–13 Hz rhythm, far faster than one wave per breath.
2. Respiratory artifact

   A slow wave in step with breathing on the electrode the head rests on is respiratory artifact; repositioning the head or lead fixes it.
3. Pulse artifact

   Pulse artifact follows the heartbeat and lines up with the ECG, not with respiration.
4. Sweat artifact

   Sweat artifact is a slow sway too, but it drifts independently of each breath.

For the AASM recommended EOG derivations (E1-M2 and E2-M2), where are E1 and E2 placed relative to the outer canthi?

1. E1 above the left canthus, E2 below the right

   This mirrors the vertical offsets; the recommended montage puts the left electrode low and the right one high.
2. Both below their canthi, at the same level

   Both electrodes low is the alternative derivation referenced to Fpz, not the recommended E1-M2/E2-M2 pair.
3. E1 below the left canthus, E2 above the right

   Placing E1 about 1 cm below the left and E2 about 1 cm above the right outer canthus makes eye movements write out-of-phase deflections in the two channels.
4. Both above their canthi, at the same level

   With both electrodes above the eyes, vertical movements no longer give opposite deflections, and no AASM derivation uses this layout.

In AASM PSG reports, the time from lights out to lights on is called:

1. Sleep period time

   Sleep period time runs from sleep onset to the final awakening, so it starts later than lights out.
2. Total monitoring time

   Monitoring time is the home-test term, the denominator of the REI, where sleep is not measured.
3. Total recording time

   AASM reports call the span from lights out to lights on total recording time and use it as the sleep-efficiency denominator.
4. Total sleep time

   Total sleep time counts only scored sleep epochs and leaves out all wake within the night.

Which finding is REQUIRED to score Cheyne–Stokes breathing?

1. A cycle length of at least 40 s

   Cheyne–Stokes needs crescendo-decrescendo cycles of 40 s or longer around at least 3 consecutive central events.
2. 3 consecutive obstructive apneas

   The events in Cheyne–Stokes breathing are central; obstructive apneas do not qualify.
3. 10 consecutive minutes of the pattern

   Ten consecutive minutes is the obsolete 2007 rule, replaced by an event rate over at least 2 h of monitoring.
4. A 4% drop in SpO2 per cycle

   A 4% drop in SpO2 per cycle is not part of the Cheyne–Stokes definition, which rests on breathing pattern and event type.

The previous epoch was definite R. The current epoch shows LAMF EEG, sawtooth waves and low chin EMG, but no REMs and no arousal. How is it scored?

1. R

   Following definite R, an epoch keeps the R label while EEG stays low-amplitude mixed-frequency and chin tone stays low, even without rapid eye movements.
2. N1

   Switching to N1 needs something to interrupt R, such as an arousal or a rise in chin tone, and nothing interrupts it here.
3. N2

   N2 needs a K complex or spindle, and none is described.
4. W

   Wake would need alpha or an arousal with raised tone, and the chin remains low.

The PSG shows REM 10 min after sleep onset. The next-day MSLT has a mean latency of 6 min with 1 SOREMP. How many SOREMPs count toward narcolepsy criteria?

1. 0

   Zero treats a SOREMP as worthless unless it appears in several naps, discarding both qualifying REM onsets.
2. 1

   Counting 1 uses only the nap and ignores the REM onset on the preceding night, which ICSD-3-TR allows to count.
3. 2

   A SOREMP within 15 min of sleep onset on the preceding night PSG can stand in for one MSLT SOREMP, so one nap SOREMP plus the PSG one makes 2.
4. 3

   Three would count the night SOREMP twice; it replaces one nap SOREMP only once.

An adult's PSG shows an AHI of 22/h. How is the OSA severity classified?

1. Severe OSA

   Severe starts at an AHI of 30 per hour or more.
2. No OSA

   Calling it no OSA ignores that normal ends below an AHI of 5, far under 22.
3. Moderate OSA

   In adults an AHI from 15 to under 30 per hour is moderate, and 22 falls inside that band.
4. Mild OSA

   Mild ends below 15 per hour, so 22 is past it.

In a patient who does not generate alpha, N1 may start at the earliest of 4–7 Hz slowing, vertex sharp waves, or:

1. Slow eye movements

   When there is no alpha to lose, N1 begins with the first of theta slowing, vertex sharp waves or slow eye movements.
2. Sleep spindles

   Spindles are an N2 feature, so they come too late to mark sleep onset.
3. K complexes

   K complexes mark N2, a later stage, not the start of N1.
4. Reduced chin EMG tone

   A drop in chin tone is not one of the N1 onset criteria; tone often falls only gradually through NREM.

In a 12-month-old, a 6-Hz occipital rhythm that attenuates with eye opening fills 20 s of an epoch, with high chin EMG. How is it scored?

1. N1

   Reading any 4–7 Hz activity as drowsiness misses that this is the child's own dominant waking rhythm.
2. W

   A reactive 5–6 Hz posterior rhythm is the normal waking rhythm at one year, and it fills more than half the epoch.
3. N2

   No spindles or K complexes are described, so N2 has no basis.
4. R

   High chin tone and a rhythm that blocks with eye opening argue against R.

TRT is 480 minutes, sleep latency 24 minutes and TST 384 minutes. Which pair of values is correct?

1. SE 80%; WASO 96 min

   Efficiency is right, but 96 min is TRT minus TST, which still includes the 24-min latency.
2. SE 84%; WASO 72 min

   WASO is right, but 84% comes from dividing by 456 min instead of the 480-min TRT.
3. SE 80%; WASO 72 min

   Efficiency is 384 ÷ 480 = 80%, and wake after sleep onset is 480 − 24 − 384 = 72 min.
4. SE 84%; WASO 96 min

   Both values are wrong: 84% drops sleep latency from the denominator and 96 min counts that latency as WASO.

Hypoglossal nerve stimulation treats OSA by:

1. Pacing the diaphragm

   Diaphragm pacing through the phrenic nerve is a central apnea treatment, a different implant.
2. Stiffening the soft palate

   Palatal stiffening is the aim of palatal implants or radiofrequency procedures, not of nerve stimulation.
3. Advancing the lower jaw

   Advancing the lower jaw is how a mandibular advancement device works.
4. Moving the tongue forward

   Stimulating the hypoglossal nerve in time with inspiration protrudes the tongue and opens the airway behind it.

Which PAP mode is designed to treat Cheyne–Stokes breathing?

1. Adaptive servo-ventilation

   Adaptive servo-ventilation varies pressure support breath by breath and has a backup rate, smoothing the crescendo-decrescendo cycle.
2. Auto-titrating CPAP

   Auto-titrating CPAP chases obstruction and can misread central pauses, raising pressure that does not help.
3. Bilevel PAP, spontaneous mode

   Spontaneous bilevel has no backup rate, and its fixed pressure support can deepen central events.
4. CPAP with expiratory relief

   Expiratory pressure relief adds no backup rate and does nothing to stabilize ventilation.

A correctly sized full-face mask leaks only at the chin. What should be tried FIRST?

1. Add a chinstrap

   A chinstrap keeps the mouth closed under a nasal mask; a full-face mask already covers the mouth.
2. Adjust the lower straps

   The lower straps set the seal at the chin, so they are the first thing to adjust for a leak there.
3. Raise the CPAP pressure

   Higher pressure pushes more air through the gap and worsens the leak.
4. Tighten the upper straps

   Tightening the upper straps tips the cushion toward the nose bridge and can open the chin gap further.

Baseline RDI is 30/h. At the final pressure, with supine REM recorded, RDI is 16/h. The AASM 2008 grade is:

1. Unacceptable

   The RDI fell from 30 to 16/h, about 47%, which meets no 2008 grade, so the titration is unacceptable.
2. Good

   Good needs an RDI of 10/h or less; the 50% option applies only when baseline is under 15/h.
3. Adequate

   Adequate needs at least a 75% fall, here down to 7.5/h or lower, and 16/h is well short of it.
4. Inconclusive

   Inconclusive is not one of the 2008 grades.

A 40-year-old with AHI 30/h and BMI 28 has never used PAP but requests hypoglossal nerve stimulation. Per the device label, the patient is:

1. Not yet; a PAP trial comes first

   Not yet: the stimulator is labeled for patients who have failed or cannot tolerate PAP, and this patient has never had a PAP trial.
2. Not a candidate; BMI is too high

   A BMI of 28 is well inside the labeled range, so a too-high BMI is not what stands in the way.
3. A candidate once DISE is done

   DISE screens airway anatomy but does not replace the requirement of PAP failure or intolerance.
4. A candidate now; AHI is in range

   An AHI of 30/h is in range, but meeting the AHI range alone does not make the patient a candidate now.

Per AASM 2008, switching a patient intolerant of high CPAP to BPAP is done mainly to improve:

1. Upper-airway patency

   The guideline notes bilevel does not hold the airway open better than CPAP at equivalent pressure.
2. Oxygen saturation

   Oxygen is addressed with supplemental O2 after events are controlled, not by changing the mode.
3. CO2 elimination in OSA

   Ventilation support is the reason for bilevel in hypoventilation, not in uncomplicated OSA.
4. Comfort on exhalation

   The 2008 guideline allows the switch for patients uncomfortable with high CPAP; a lower expiratory pressure gives comfort on exhalation without claiming better airway control.

Which patient is a poor candidate for home APAP instead of in-lab titration?

1. Hypercapnic COPD with OSA

   Hypercapnic COPD is significant lung disease with hypoventilation, which APAP cannot manage, so this patient needs attended titration.
2. Severe OSA, no comorbidities

   Severe OSA with no comorbidities is still suitable for APAP, since severity alone does not exclude it.
3. OSA with nasal allergies

   Nasal congestion is handled with humidification or a different interface and does not bar home APAP.
4. Uncomplicated moderate OSA

   Uncomplicated moderate OSA is the textbook case for starting APAP at home.

During CPAP titration of a patient younger than 12, AASM 2008 calls for a pressure increase after at least how many RERAs?

1. 2 RERAs

   2 RERAs is not a threshold at any age; two is the adult count for obstructive apneas.
2. 1 RERA

   1 RERA borrows the pediatric threshold for obstructive apneas and hypopneas, which is one event.
3. 5 RERAs

   Five RERAs is the threshold for patients 12 and older.
4. 3 RERAs

   Under 12, three RERAs prompt a pressure increase, a lower bar than in older patients.