From my research into this topic (I have a 2010 5.4 F250), the rattle sound at start up can come from the cam phasers lacking initial oil pressure. The pins that lock the phasers (or sore something like that) are worn out from lack of oil over its life, so they rattle a bit until the oil is sufficient. I bet if you went through a drive-thru you can hear it knock at idle and goes away with rpms. I did new phasers, timing kit, and Melling oil pump and 5W30 oil every 5-6k miles almost a year ago now. Problem solved and power restored. Zero issues to date. Also the belt tensioners are oil driven and the stock ones blow out the seals, new motorcraft ones fix that problem. So if its a tensioner guide knocking around, thats probably why.
I would recommend the following if he intends to keep the truck.
- New MOTORCRAFT phasers
- Melling M360 oil pump (it fixes the oil deliver issue ford decided was okay)
- MOTORCRAFT Timing Kit
If you do not buy motorcraft phasers, you are asking for trouble.
For bonus points.
- Updated Motorcraft Rocker Arms (They have improved oil passages so the cams are properly oiled)
- New VCT Solenoids (because you are there)
You can buy parts for about a $1000. Shop Labor is usually $1500-2000 depending on if you go for bonus points (of course this all varies by area etc).
Just my .02.