In this way, much of the moment-to-moment play in Medieval is familiar to earlier Sims games. In addition to the quests they may help complete, each specialist hero must also fulfill the everyday duties of his or her profession. Challenges become more dangerous and rewarding as the kingdom grows in size and power. New buildings and rooms are acquired with points earned by completing quests. By adding a new workshop or castle wing, for example, players may be able to invite a merchant or spy to join the realm. As in many city-management games and other real-time strategies, players unlock new character types for their adventures by constructing the appropriate support buildings in their town. Some quests will call for the skills of two or three specialists, with one character serving as the leader and the others working in support. Most quests can be accomplished in multiple ways, however, with the particular skill set of nearly any type of Sim specialist. The different tasks of a Medieval kingdom require different specialist citizens, including priests, physicians, and smiths, as well as wizards, knights, and monarchs.

Players invent the adventure that takes place in between, through the characters they customize and the quests they accept. Unlike in previous games from the best-selling PC series, a Sims Medieval story has a beginning and ending. As the kingdom grows in power and prosperity, new ambitions lead to new quests, and new heroes become available. Once they've established a goal, players may recruit great heroes to embark upon noble quests that will help the kingdom reach it. Similar to the character ambitions in earlier Sims games, a variety of kingdom ambitions is available from which to choose, with many based in desires for health, wealth, or power. Instead of focusing on the lives of individual characters, Medieval players guide the development of their own storybook kingdoms, which are driven by ambitions of their choosing. Moving its people-management play from familiar suburban settings to a fairy tale realm of knights and knaves, The Sims Medieval adds aspects of role-playing and city-building games to the series' life-simulation.

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